Provider Demographics
NPI:1376897793
Name:WADA, KEISUKE (DMD)
Entity Type:Individual
Prefix:DR
First Name:KEISUKE
Middle Name:
Last Name:WADA
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 1:150 E WYNNEWOOD RD
Mailing Address - Street 2:#2A
Mailing Address - City:WYNNEWOOD
Mailing Address - State:PA
Mailing Address - Zip Code:19096
Mailing Address - Country:US
Mailing Address - Phone:610-649-0570
Mailing Address - Fax:
Practice Address - Street 1:3401 MARKET STREET
Practice Address - Street 2:SUITE 110
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104
Practice Address - Country:US
Practice Address - Phone:215-573-8400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-07
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0393761223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics