Provider Demographics
NPI:1487704433
Name:WAFELBAKKER, BAS W (DMD)
Entity type:Individual
Prefix:DR
First Name:BAS
Middle Name:W
Last Name:WAFELBAKKER
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 1:17705 HALE AVE STE G2
Mailing Address - Street 2:
Mailing Address - City:MORGAN HILL
Mailing Address - State:CA
Mailing Address - Zip Code:95037-4350
Mailing Address - Country:US
Mailing Address - Phone:408-776-9112
Mailing Address - Fax:408-776-8141
Practice Address - Street 1:17705 HALE AVE STE G2
Practice Address - Street 2:
Practice Address - City:MORGAN HILL
Practice Address - State:CA
Practice Address - Zip Code:95037-4350
Practice Address - Country:US
Practice Address - Phone:408-776-9112
Practice Address - Fax:408-776-8141
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA034790174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist