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General NPI Number Information
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NPI Number | 1528195377
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Entity Type | Organization
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Legal Business Name | WAITE FAMILY DENTAL, LLC
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Dates
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Enumeration Date | 02/28/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 580 KASE ST
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City | PLATTEVILLE
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State | WI
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Zip | 53818-1814
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Country | US
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Telephone | 608-348-3031
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Fax | 608-348-9739
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Provider Business Mailing Address
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Address Line | 580 KASE ST P.O. BOX 255
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City | PLATTEVILLE
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State | WI
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Zip | 53818-1814
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Country | US
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Telephone | 608-348-3031
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Fax | 608-348-9739
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Authorized Official
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Title or Position | GENERAL DENTIST
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Name | DR. JAN M WAITE
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Credential | D.D.S.
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Telephone | 608-348-3031
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 4104
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License Number State | WI
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