Provider Demographics
NPI:1528753688
Name:WIDNER, CALEB ODUM (DDS)
Entity type:Individual
Prefix:
First Name:CALEB
Middle Name:ODUM
Last Name:WIDNER
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 1:310 N LINDEN AVE
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23075-1902
Mailing Address - Country:US
Mailing Address - Phone:276-698-9908
Mailing Address - Fax:
Practice Address - Street 1:350 BLOUNTVILLE HWY
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-0213
Practice Address - Country:US
Practice Address - Phone:423-968-9661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-05
Last Update Date:2025-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014193591223P0221X
390200000X
TN127831223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program