Provider Demographics
NPI:1366681082
Name:WAYNEWOOD & ASSOCIATES, P.A.
Entity Type:Organization
Organization Name:WAYNEWOOD & ASSOCIATES, P.A.
Other - Org Name:KINGFIELD FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NESRET
Authorized Official - Middle Name:
Authorized Official - Last Name:SHU-ANKH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-647-9697
Mailing Address - Street 1:393 DUNLAP ST N
Mailing Address - Street 2:SUITE 650
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-4200
Mailing Address - Country:US
Mailing Address - Phone:651-647-9697
Mailing Address - Fax:651-646-2771
Practice Address - Street 1:17 E 38TH ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55409-1341
Practice Address - Country:US
Practice Address - Phone:612-353-5443
Practice Address - Fax:612-353-5440
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAYNEWOOD & ASSOCIATES, P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-02-19
Last Update Date:2009-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND80841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty