Provider Demographics
NPI:1790938942
Name:EVANS-WENZEL, M CLYDENE (RDH)
Entity Type:Individual
Prefix:MS
First Name:M
Middle Name:CLYDENE
Last Name:EVANS-WENZEL
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2733 56TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98116-2221
Mailing Address - Country:US
Mailing Address - Phone:206-932-8861
Mailing Address - Fax:
Practice Address - Street 1:425 SW 144TH ST
Practice Address - Street 2:
Practice Address - City:BURIEN
Practice Address - State:WA
Practice Address - Zip Code:98166-1545
Practice Address - Country:US
Practice Address - Phone:206-355-0448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-01
Last Update Date:2008-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADH00006149124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist