Provider Demographics
NPI:1285720144
Name:VAN DERHEI, WENONA B (DDS)
Entity type:Individual
Prefix:DR
First Name:WENONA
Middle Name:B
Last Name:VAN DERHEI
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 1:3590 BRASELTON HWY STE 103
Mailing Address - Street 2:
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-1120
Mailing Address - Country:US
Mailing Address - Phone:678-318-3353
Mailing Address - Fax:678-318-3350
Practice Address - Street 1:3590 BRASELTON HWY STE 103
Practice Address - Street 2:
Practice Address - City:DACULA
Practice Address - State:GA
Practice Address - Zip Code:30019-1120
Practice Address - Country:US
Practice Address - Phone:678-318-3353
Practice Address - Fax:678-318-3350
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0118541223G0001X, 1223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
No1223G0001XDental ProvidersDentistGeneral Practice