Provider Demographics
NPI:1487359717
Name:TADESSE, WONGELAWIT DELDIL (DDS)
Entity type:Individual
Prefix:
First Name:WONGELAWIT
Middle Name:DELDIL
Last Name:TADESSE
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 1:551 SETTLERS LANDING RD APT 405
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23669-4251
Mailing Address - Country:US
Mailing Address - Phone:703-489-1056
Mailing Address - Fax:
Practice Address - Street 1:2417 MCGUIRE BLVD
Practice Address - Street 2:
Practice Address - City:MC GUIRE AFB
Practice Address - State:NJ
Practice Address - Zip Code:08641-5116
Practice Address - Country:US
Practice Address - Phone:609-754-3786
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-04
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1349179199261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice