Provider Demographics
NPI:1336305697
Name:WOOLDRIDGE, JEDEDIAH WALKER
Entity Type:Individual
Prefix:
First Name:JEDEDIAH
Middle Name:WALKER
Last Name:WOOLDRIDGE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7674 EAST MINNEZONA AVENUE
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85251
Mailing Address - Country:US
Mailing Address - Phone:646-825-1851
Mailing Address - Fax:
Practice Address - Street 1:3923 E CAMELBACK RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85018-2609
Practice Address - Country:US
Practice Address - Phone:646-825-1851
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-05
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY054043122300000X
AZD008267122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist