Provider Demographics
NPI:1598758427
Name:WADDY, SAVANNAH (DDS)
Entity Type:Individual
Prefix:MS
First Name:SAVANNAH
Middle Name:
Last Name:WADDY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 E CARSON PLAZA CT
Mailing Address - Street 2:101
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90746-3289
Mailing Address - Country:US
Mailing Address - Phone:310-323-4543
Mailing Address - Fax:310-323-4548
Practice Address - Street 1:520 E CARSON PLAZA CT
Practice Address - Street 2:101
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90746-3289
Practice Address - Country:US
Practice Address - Phone:310-323-4543
Practice Address - Fax:310-323-4548
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD311361223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA508101Medicaid
CAD3113601Medicaid
CAD31136Medicare ID - Type Unspecified
CAD3113601Medicaid