Healthcare Provider Details

I. General information

NPI: 1982615647
Provider Name (Legal Business Name): WAYNE ALLEN ALDREDGE DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 CENTRE ST
NUTLEY NJ
07110
US

IV. Provider business mailing address

230 CENTRE ST
NUTLEY NJ
07110
US

V. Phone/Fax

Practice location:
  • Phone: 973-661-2992
  • Fax: 973-661-3513
Mailing address:
  • Phone: 973-661-2992
  • Fax: 973-661-3513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberD118768
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: