Provider Demographics
NPI:1093096364
Name:WADE, DANIELLE MAGRO (DDS)
Entity Type:Individual
Prefix:DR
First Name:DANIELLE
Middle Name:MAGRO
Last Name:WADE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:855 CREEKSTONE RDG
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-9469
Mailing Address - Country:US
Mailing Address - Phone:304-685-7932
Mailing Address - Fax:
Practice Address - Street 1:855 CREEKSTONE RDG
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-9469
Practice Address - Country:US
Practice Address - Phone:304-685-7932
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-31
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV39041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice