Provider Demographics
NPI:1386848414
Name:MAIBAUM, WAYNE WILLIAM (DMD)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:WILLIAM
Last Name:MAIBAUM
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 1:34 PLEASANT RIDGE RD EXT
Mailing Address - Street 2:
Mailing Address - City:POUGHQUAG
Mailing Address - State:NY
Mailing Address - Zip Code:12570-4952
Mailing Address - Country:US
Mailing Address - Phone:845-724-4352
Mailing Address - Fax:845-724-4352
Practice Address - Street 1:939 ROUTE 376
Practice Address - Street 2:SUITE 1
Practice Address - City:WAPPINGERS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12590
Practice Address - Country:US
Practice Address - Phone:845-223-9987
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY386541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice