Provider Demographics
NPI:1134220130
Name:WADSWORTH, JOEL RUSSELL JR (DMD)
Entity type:Individual
Prefix:DR
First Name:JOEL
Middle Name:RUSSELL
Last Name:WADSWORTH
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 3817
Mailing Address - Street 2:
Mailing Address - City:BELLEVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:34421-3817
Mailing Address - Country:US
Mailing Address - Phone:352-750-0008
Mailing Address - Fax:352-259-9145
Practice Address - Street 1:13940 N US HIGHWAY 441
Practice Address - Street 2:SUITE 602
Practice Address - City:LADY LAKE
Practice Address - State:FL
Practice Address - Zip Code:32159-8908
Practice Address - Country:US
Practice Address - Phone:352-750-0008
Practice Address - Fax:352-259-9145
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN14051122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist