Provider Demographics
NPI:1063590503
Name:WENZELL, DOMINIC STEVE (DMD)
Entity type:Individual
Prefix:
First Name:DOMINIC
Middle Name:STEVE
Last Name:WENZELL
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:PO BOX 640
Mailing Address - Street 2:
Mailing Address - City:GIRDWOOD
Mailing Address - State:AK
Mailing Address - Zip Code:99587-0640
Mailing Address - Country:US
Mailing Address - Phone:907-230-1940
Mailing Address - Fax:
Practice Address - Street 1:5855 W UTOPIA RD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-5251
Practice Address - Country:US
Practice Address - Phone:623-537-6000
Practice Address - Fax:623-806-7010
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD83091223G0001X
WADE000096791223G0001X
AKAK11161223G0001X
AZDO115761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKDD54213Medicaid
AK1533613OtherUNITED CONCORDIA ID NUM.