Provider Demographics
NPI:1508936766
Name:WANNER, NEAL BRADLEY (DDS)
Entity Type:Individual
Prefix:
First Name:NEAL
Middle Name:BRADLEY
Last Name:WANNER
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 1:120 STATE AVE N
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98030-4554
Mailing Address - Country:US
Mailing Address - Phone:253-630-4542
Mailing Address - Fax:
Practice Address - Street 1:120 STATE AVE N
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98030-4554
Practice Address - Country:US
Practice Address - Phone:253-852-3929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA251-030005883122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist