Provider Demographics
NPI:1447373121
Name:TADSEN, WAYNE THEODORE (DMD)
Entity type:Individual
Prefix:
First Name:WAYNE
Middle Name:THEODORE
Last Name:TADSEN
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 1:102 GORDON ST
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-6910
Mailing Address - Country:US
Mailing Address - Phone:770-995-6215
Mailing Address - Fax:770-995-6263
Practice Address - Street 1:102 GORDON ST
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-6910
Practice Address - Country:US
Practice Address - Phone:770-995-6215
Practice Address - Fax:770-995-6263
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0086261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice