Provider Demographics
NPI:1508874777
Name:SHAFFER, WENDELL WILSON (DDS)
Entity Type:Individual
Prefix:DR
First Name:WENDELL
Middle Name:WILSON
Last Name:SHAFFER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17601 W 130TH ST
Mailing Address - Street 2:
Mailing Address - City:N ROYALTON
Mailing Address - State:OH
Mailing Address - Zip Code:44133
Mailing Address - Country:US
Mailing Address - Phone:440-582-0550
Mailing Address - Fax:440-582-0550
Practice Address - Street 1:17601 W 130TH ST
Practice Address - Street 2:
Practice Address - City:N ROYALTON
Practice Address - State:OH
Practice Address - Zip Code:44256
Practice Address - Country:US
Practice Address - Phone:440-582-0550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30016249122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist