Provider Demographics
NPI:1871551861
Name:WADDELL, REGGIE M (DDS)
Entity type:Individual
Prefix:DR
First Name:REGGIE
Middle Name:M
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 1:3629 NEAL DR
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37918-5312
Mailing Address - Country:US
Mailing Address - Phone:865-922-7471
Mailing Address - Fax:865-925-4829
Practice Address - Street 1:3629 NEAL DR
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37918-5312
Practice Address - Country:US
Practice Address - Phone:865-922-7471
Practice Address - Fax:865-925-4829
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS 31361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN47674OtherDHA
TN0000136OtherFORTIS/ASSURANT
TN2000187OtherBCBSTN
TN104396OtherCIGNA HMO