Provider Demographics
NPI:1063790194
Name:WADDELL, RICHARD WAYNE (DDS)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:WAYNE
Last Name:WADDELL
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 1:704 ARBOR LN
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31028-8614
Mailing Address - Country:US
Mailing Address - Phone:404-316-2145
Mailing Address - Fax:
Practice Address - Street 1:655 7TH ST BLDG 700700-A
Practice Address - Street 2:SGHC CREDENTIALS
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31098-2227
Practice Address - Country:US
Practice Address - Phone:478-327-8095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-22
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60426390200000X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program