Provider Demographics
NPI:1962522532
Name:KING, WENDELL (DMD)
Entity type:Individual
Prefix:DR
First Name:WENDELL
Middle Name:
Last Name:KING
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 1:1855 W NOB HILL ST SE STE 200
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-5288
Mailing Address - Country:US
Mailing Address - Phone:503-588-0061
Mailing Address - Fax:
Practice Address - Street 1:1855 W NOB HILL ST SE STE 200
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-5288
Practice Address - Country:US
Practice Address - Phone:503-588-0061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
ORD84681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies