Provider Demographics
NPI:1457366023
Name:WADDELL, HENRY (DDS)
Entity type:Individual
Prefix:
First Name:HENRY
Middle Name:
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 1:143 S NUECES PARK LN
Mailing Address - Street 2:
Mailing Address - City:HARLINGEN
Mailing Address - State:TX
Mailing Address - Zip Code:78552-6233
Mailing Address - Country:US
Mailing Address - Phone:956-495-7433
Mailing Address - Fax:
Practice Address - Street 1:1205 E ALTON GLOOR BLVD
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78526-3831
Practice Address - Country:US
Practice Address - Phone:956-542-1956
Practice Address - Fax:956-542-3672
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17379122300000X, 1223G0001X
CA525441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX184357510Medicaid