Provider Demographics
NPI:1104453075
Name:WHEELOCK, JOHN HARDIE
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:HARDIE
Last Name:WHEELOCK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15810 S 45TH ST STE 120
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85048-7695
Mailing Address - Country:US
Mailing Address - Phone:480-893-3636
Mailing Address - Fax:480-893-3635
Practice Address - Street 1:15810 S 45TH ST STE 120
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85048-7695
Practice Address - Country:US
Practice Address - Phone:480-893-3636
Practice Address - Fax:480-893-3635
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-23
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0119871223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery