Provider Demographics
NPI:1003988064
Name:COTTAM, WAYNE WILKINSON (DMD)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:WILKINSON
Last Name:COTTAM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10465 E PLATA AVE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85212-1840
Mailing Address - Country:US
Mailing Address - Phone:480-984-4002
Mailing Address - Fax:
Practice Address - Street 1:4212 N 16TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-5319
Practice Address - Country:US
Practice Address - Phone:602-263-1511
Practice Address - Fax:602-263-1637
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD74461223G0001X
IDD31021223G0001X
UT272632-99221223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ857740Medicaid
AZ0410520OtherBCBS