Provider Demographics
NPI:1396756508
Name:WADDELL, STANLEY R (DDS)
Entity type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:R
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 1:1900 KIRBY PKWY
Mailing Address - Street 2:SUITE200
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-3610
Mailing Address - Country:US
Mailing Address - Phone:901-756-8855
Mailing Address - Fax:901-756-8752
Practice Address - Street 1:1900 KIRBY PKWY
Practice Address - Street 2:SUITE200
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-3610
Practice Address - Country:US
Practice Address - Phone:901-756-8855
Practice Address - Fax:901-756-8752
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN39361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice