Provider Demographics
NPI:1063081917
Name:WHEATLEY, AUSTIN (DMD)
Entity type:Individual
Prefix:
First Name:AUSTIN
Middle Name:
Last Name:WHEATLEY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6900 E PRINCESS DR UNIT 2254
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85054-4125
Mailing Address - Country:US
Mailing Address - Phone:641-740-7660
Mailing Address - Fax:
Practice Address - Street 1:6900 E PRINCESS DR UNIT 2254
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85054-4125
Practice Address - Country:US
Practice Address - Phone:641-740-7660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-23
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL260161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice