Provider Demographics
NPI:1306142815
Name:WRATHALL, JODY LYNN (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:JODY
Middle Name:LYNN
Last Name:WRATHALL
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:MS
Other - First Name:JODY
Other - Middle Name:LYNN
Other - Last Name:CHAPMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:3020 OLD CENTRE RD.
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024
Mailing Address - Country:US
Mailing Address - Phone:269-323-8016
Mailing Address - Fax:269-323-8524
Practice Address - Street 1:3020 OLD CENTRE RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024
Practice Address - Country:US
Practice Address - Phone:269-328-8016
Practice Address - Fax:269-323-8524
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-31
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901020339122300000X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist