MEDICARE: WAYNE NG DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	319010921	IL

General Provider Information

NPI Number	:	1215146774
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WAYNE NG DDS

Provider Business Mailing Address
First Line	:	2054 W DEVON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60659-2128
Country	:	US
Telephone Number	:	773-465-8901
Fax Number	:	847-324-9476

Provider Business Practice Location Address
First Line	:	2054 W DEVON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60659-2128
Country	:	US
Telephone Number	:	773-465-8901
Fax Number	:	847-324-9476

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/22/2007
Last Update Date	:	11/06/2024

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