Basic Information
| Provider Information | |||||||||
| NPI: | 1932828548 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WENDELL | ||||||||
| FirstName: | TERRI | ||||||||
| MiddleName: | |||||||||
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| Credential: | DENTAL HYGIENIST | ||||||||
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| Mailing Information | |||||||||
| Address1: | 58 BURR DR | ||||||||
| Address2: | |||||||||
| City: | DALTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 012261316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4136841029 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 510 NORTH ST STE 2 | ||||||||
| Address2: | |||||||||
| City: | PITTSFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 012014111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4134472781 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2022 | ||||||||
| LastUpdateDate: | 08/25/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | 9715 | MA | Y | Dental Providers | Dental Hygienist |
ID Information
| ID | Type | State | Issuer | Description | 9715 | 05 | MA | MEDICAID |