Provider Demographics
NPI:1770653008
Name:PHELPS, WENDELL WARREN JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:WENDELL
Middle Name:WARREN
Last Name:PHELPS
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 BOMAN ST
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:MI
Mailing Address - Zip Code:48433-1787
Mailing Address - Country:US
Mailing Address - Phone:810-659-8471
Mailing Address - Fax:810-659-8499
Practice Address - Street 1:220 BOMAN ST
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:MI
Practice Address - Zip Code:48433-1787
Practice Address - Country:US
Practice Address - Phone:810-659-8471
Practice Address - Fax:810-659-8499
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI8120122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist