Provider Demographics
NPI:1821248790
Name:WENDY MEDDERS MACKE DMD PC
Entity Type:Organization
Organization Name:WENDY MEDDERS MACKE DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:MEDDERS
Authorized Official - Last Name:MACKE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:678-908-5866
Mailing Address - Street 1:4240 ANCROFT CIR
Mailing Address - Street 2:
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30092-2664
Mailing Address - Country:US
Mailing Address - Phone:678-908-5866
Mailing Address - Fax:
Practice Address - Street 1:76 NORCROSS ST
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-3866
Practice Address - Country:US
Practice Address - Phone:770-993-0265
Practice Address - Fax:770-998-7307
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-26
Last Update Date:2008-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0124271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1831282193OtherINDIVIDUAL NPI #