Healthcare Provider Details

I. General information

NPI: 1518462373
Provider Name (Legal Business Name): WAYNE THOMAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2018
Last Update Date: 07/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1981 S STATE ST
DOVER DE
19901
US

IV. Provider business mailing address

1981 S STATE ST
DOVER DE
19901-5811
US

V. Phone/Fax

Practice location:
  • Phone: 302-697-1152
  • Fax:
Mailing address:
  • Phone: 302-697-1152
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberG1-0001446
License Number StateDE
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: