Provider Demographics
NPI:1821482167
Name:WACKER, MENDEE (RDH, BS)
Entity Type:Individual
Prefix:
First Name:MENDEE
Middle Name:
Last Name:WACKER
Suffix:
Gender:F
Credentials:RDH, BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1204 ATWOOD ST
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-3421
Mailing Address - Country:US
Mailing Address - Phone:970-215-7884
Mailing Address - Fax:
Practice Address - Street 1:1204 ATWOOD ST
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-3421
Practice Address - Country:US
Practice Address - Phone:970-215-7884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-25
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2023626124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist