Provider Demographics
NPI:1871952820
Name:WADE FAMILY DENTAL
Entity type:Organization
Organization Name:WADE FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:WADE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:262-542-4466
Mailing Address - Street 1:1547 E RACINE AVE
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-6826
Mailing Address - Country:US
Mailing Address - Phone:262-542-4466
Mailing Address - Fax:262-542-6105
Practice Address - Street 1:1547 E RACINE AVE
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-6826
Practice Address - Country:US
Practice Address - Phone:262-542-4466
Practice Address - Fax:262-542-6105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-18
Last Update Date:2016-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIW3829305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33684200Medicaid