Provider Demographics
NPI:1891817615
Name:E PELL WADLEIGH DDS PC
Entity Type:Organization
Organization Name:E PELL WADLEIGH DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:PELL
Authorized Official - Last Name:WADLEIGH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:928-645-2505
Mailing Address - Street 1:PO BOX 2
Mailing Address - Street 2:436 VISTA AVE
Mailing Address - City:PAGE
Mailing Address - State:AZ
Mailing Address - Zip Code:86040-0002
Mailing Address - Country:US
Mailing Address - Phone:928-645-2505
Mailing Address - Fax:928-645-6820
Practice Address - Street 1:436 VISTA AVE
Practice Address - Street 2:
Practice Address - City:PAGE
Practice Address - State:AZ
Practice Address - Zip Code:86040-0002
Practice Address - Country:US
Practice Address - Phone:928-645-2505
Practice Address - Fax:928-645-6820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2639207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty