Provider Demographics
NPI:1831282193
Name:MACKE, WENDY MEDDERS (DMD)
Entity Type:Individual
Prefix:DR
First Name:WENDY
Middle Name:MEDDERS
Last Name:MACKE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:WENDY
Other - Middle Name:M
Other - Last Name:MEDDERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
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:770-613-0626
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:770-569-0377
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-01
Last Update Date:2008-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0124271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice