Provider Demographics
NPI:1528361136
Name:WAFELBAKKER ANDERSON ORTHODONTICS SOUTH COUNTY
Entity Type:Organization
Organization Name:WAFELBAKKER ANDERSON ORTHODONTICS SOUTH COUNTY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BAS
Authorized Official - Middle Name:W
Authorized Official - Last Name:WAFELBAKKER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:408-776-9112
Mailing Address - Street 1:17705 HALE AVE STE G2
Mailing Address - Street 2:
Mailing Address - City:MORGAN HILL
Mailing Address - State:CA
Mailing Address - Zip Code:95037-4350
Mailing Address - Country:US
Mailing Address - Phone:408-776-9112
Mailing Address - Fax:408-776-8141
Practice Address - Street 1:17705 HALE AVE STE G-2
Practice Address - Street 2:
Practice Address - City:MORGAN HILL
Practice Address - State:CA
Practice Address - Zip Code:95037-4350
Practice Address - Country:US
Practice Address - Phone:408-776-9112
Practice Address - Fax:408-776-8141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-21
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0347901223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty