Provider Demographics
NPI:1114096427
Name:CLAIBORNE, WAYNE L (DDS)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:L
Last Name:CLAIBORNE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10552 W GARVERDALE COURT
Mailing Address - Street 2:SUITE 902
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-5478
Mailing Address - Country:US
Mailing Address - Phone:208-336-4777
Mailing Address - Fax:
Practice Address - Street 1:10552 W GARVERDALE COURT
Practice Address - Street 2:SUITE 902
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-5478
Practice Address - Country:US
Practice Address - Phone:208-336-4777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD1896122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000979800Medicaid