Healthcare Provider Details

I. General information

NPI: 1457467524
Provider Name (Legal Business Name): JOHN T WAITE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4400 HAVERFORD AVE HEALTH CENTER #4
PHILADELPHIA PA
19104-1361
US

IV. Provider business mailing address

500 S BROAD ST DENTAL SUITE
PHILADELPHIA PA
19146-1613
US

V. Phone/Fax

Practice location:
  • Phone: 215-685-7630
  • Fax: 215-386-4902
Mailing address:
  • Phone: 215-685-6768
  • Fax: 215-685-6891

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS026358L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: