Provider Demographics
NPI:1669587382
Name:WANZO, JOHN EDWARD (DDS)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:EDWARD
Last Name:WANZO
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 1:737 W CHILDS AVE
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95341-6805
Mailing Address - Country:US
Mailing Address - Phone:209-383-1848
Mailing Address - Fax:209-383-1296
Practice Address - Street 1:9235 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PLANADA
Practice Address - State:CA
Practice Address - Zip Code:95365-8088
Practice Address - Country:US
Practice Address - Phone:209-382-1697
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30137122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA30137OtherDENTAL LICENSE
CA30137OtherDENTAL LICENSE