Healthcare Provider Details

I. General information

NPI: 1447581392
Provider Name (Legal Business Name): WAYNE R. SMITH D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2010
Last Update Date: 01/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

656 N. WELLWOOD AVE LOUIS LASKY MEMORIAL MEDICAL & DENTAL CENTER
LINDENHURST NY
11757
US

IV. Provider business mailing address

65 GLENGARIFF RD.
MASSAPEQUA PARK NY
11762-3022
US

V. Phone/Fax

Practice location:
  • Phone: 631-225-1010
  • Fax:
Mailing address:
  • Phone: 516-826-8967
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number042071-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: