Provider Demographics
NPI:1710376470
Name:WEDGEWOOD DENTAL L.L.C.
Entity Type:Organization
Organization Name:WEDGEWOOD DENTAL L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name::LINDA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:WESTMORELAND
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:573-368-7325
Mailing Address - Street 1:713 SALEM AVE STE A
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-3444
Mailing Address - Country:US
Mailing Address - Phone:573-368-7325
Mailing Address - Fax:573-364-7326
Practice Address - Street 1:713 SALEM AVE STE A
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-3444
Practice Address - Country:US
Practice Address - Phone:573-368-7325
Practice Address - Fax:573-364-7326
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-20
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO015865261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental