Provider Demographics
NPI:1770658148
Name:WOODALL, WENDY SUE (DDS)
Entity Type:Individual
Prefix:DR
First Name:WENDY
Middle Name:SUE
Last Name:WOODALL
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 1:1001 SHADOW LN
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-4124
Mailing Address - Country:US
Mailing Address - Phone:702-774-2722
Mailing Address - Fax:702-774-2499
Practice Address - Street 1:222 RICK FRANCIS ST # 24001
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79905-2817
Practice Address - Country:US
Practice Address - Phone:915-215-5856
Practice Address - Fax:702-774-2499
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX145931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100510154Medicaid
NV100510154Medicaid