Provider Demographics
NPI:1407979099
Name:WAYNE T. TADSEN DMD PC
Entity Type:Organization
Organization Name:WAYNE T. TADSEN DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:THEODORE
Authorized Official - Last Name:TADSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:770-995-6215
Mailing Address - Street 1:102 GORDON ST
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-6910
Mailing Address - Country:US
Mailing Address - Phone:770-995-6215
Mailing Address - Fax:770-995-6263
Practice Address - Street 1:102 GORDON ST
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-6910
Practice Address - Country:US
Practice Address - Phone:770-995-6215
Practice Address - Fax:770-995-6263
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0086261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty