Provider Demographics
NPI:1659568921
Name:MORETA, WANDA E (DMD)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:E
Last Name:MORETA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:WANDA
Other - Middle Name:E
Other - Last Name:VILLAMIL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4325 STAGE RD STE 2
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38128-5739
Mailing Address - Country:US
Mailing Address - Phone:901-385-2853
Mailing Address - Fax:901-385-9080
Practice Address - Street 1:4325 STAGE RD STE 2
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38128-5739
Practice Address - Country:US
Practice Address - Phone:901-385-2853
Practice Address - Fax:901-385-9080
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-01
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS5418122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3225856Medicaid