Provider Demographics
NPI:1710366109
Name:DEAN, WARDELL III (RPSGT)
Entity type:Individual
Prefix:
First Name:WARDELL
Middle Name:
Last Name:DEAN
Suffix:III
Gender:M
Credentials:RPSGT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4031 E TEAL ESTATES CIR
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:TX
Mailing Address - Zip Code:77545-8852
Mailing Address - Country:US
Mailing Address - Phone:713-498-6523
Mailing Address - Fax:
Practice Address - Street 1:4031 E TEAL ESTATES CIR
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:TX
Practice Address - Zip Code:77545-8852
Practice Address - Country:US
Practice Address - Phone:713-498-6523
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-19
Last Update Date:2015-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21356247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other