Provider Demographics
NPI:1598825374
Name:WHEELER, MARK DELWYN (DMD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:DELWYN
Last Name:WHEELER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 N ESTRELLA PKWY
Mailing Address - Street 2:SUITE B-1
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-4135
Mailing Address - Country:US
Mailing Address - Phone:623-882-0782
Mailing Address - Fax:623-882-0878
Practice Address - Street 1:500 N ESTRELLA PKWY
Practice Address - Street 2:SUITE B-1
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-4135
Practice Address - Country:US
Practice Address - Phone:623-882-0782
Practice Address - Fax:623-882-0878
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5594122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist