Provider Demographics
NPI:1093777120
Name:WALDRON, PENDLETON GLASS (DDS PA)
Entity Type:Individual
Prefix:DR
First Name:PENDLETON
Middle Name:GLASS
Last Name:WALDRON
Suffix:
Gender:M
Credentials:DDS PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 WEST 20TH ST
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:NC
Mailing Address - Zip Code:28658
Mailing Address - Country:US
Mailing Address - Phone:828-464-9220
Mailing Address - Fax:828-464-9234
Practice Address - Street 1:430 WEST 20TH ST
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:NC
Practice Address - Zip Code:28658
Practice Address - Country:US
Practice Address - Phone:828-464-9220
Practice Address - Fax:828-464-9234
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC32331223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8998815Medicaid
NC98815OtherBCBS
NC98815OtherBCBS