Provider Demographics
NPI:1649278557
Name:SUDDARTH, WESLEY A (DDS)
Entity type:Individual
Prefix:DR
First Name:WESLEY
Middle Name:A
Last Name:SUDDARTH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 97
Mailing Address - Street 2:111 S. PUBLIC SQ
Mailing Address - City:ALEXANDRIA
Mailing Address - State:TN
Mailing Address - Zip Code:37012-0097
Mailing Address - Country:US
Mailing Address - Phone:615-529-2895
Mailing Address - Fax:
Practice Address - Street 1:111 S. PUBLIC SQ
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:TN
Practice Address - Zip Code:37012-0097
Practice Address - Country:US
Practice Address - Phone:615-529-2895
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS 33171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice