Provider Demographics
NPI:1134109069
Name:HOLDBROOK, WENDELL (DMD)
Entity Type:Individual
Prefix:DR
First Name:WENDELL
Middle Name:
Last Name:HOLDBROOK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 HADDONFIELD BERLIN RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GIBBSBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08026-1228
Mailing Address - Country:US
Mailing Address - Phone:856-783-0444
Mailing Address - Fax:856-783-0445
Practice Address - Street 1:250 HADDONFIELD BERLIN RD
Practice Address - Street 2:SUITE 101
Practice Address - City:GIBBSBORO
Practice Address - State:NJ
Practice Address - Zip Code:08026-1228
Practice Address - Country:US
Practice Address - Phone:856-783-0444
Practice Address - Fax:856-783-0445
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-18
Last Update Date:2012-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22D1022982031223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ262231139Medicaid