Healthcare Provider Details

I. General information

NPI: 1003988064
Provider Name (Legal Business Name): WAYNE WILKINSON COTTAM DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 10/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4212 N 16TH ST
PHOENIX AZ
85016-5319
US

IV. Provider business mailing address

10465 E PLATA AVE
MESA AZ
85212-1840
US

V. Phone/Fax

Practice location:
  • Phone: 602-263-1511
  • Fax: 602-263-1637
Mailing address:
  • Phone: 480-984-4002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number272632-9922
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD7446
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD3102
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: