Provider Demographics
NPI:1194906735
Name:WALES, JOANNA VAUGHEY (DDS)
Entity type:Individual
Prefix:DR
First Name:JOANNA
Middle Name:VAUGHEY
Last Name:WALES
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 W LEWIS ST
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:MT
Mailing Address - Zip Code:59047-3011
Mailing Address - Country:US
Mailing Address - Phone:406-922-0881
Mailing Address - Fax:
Practice Address - Street 1:112 W LEWIS ST
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:MT
Practice Address - Zip Code:59047-3011
Practice Address - Country:US
Practice Address - Phone:406-922-0881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-26
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT20711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice