Provider Demographics
NPI:1568833648
Name:MCCANE, WANDA LOU (RDH)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:LOU
Last Name:MCCANE
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8333 WOODCREST DR NE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341-8507
Mailing Address - Country:US
Mailing Address - Phone:616-340-8674
Mailing Address - Fax:
Practice Address - Street 1:101 SHELDON BLVD SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4262
Practice Address - Country:US
Practice Address - Phone:616-776-2363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-14
Last Update Date:2015-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902006758124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist