Provider Demographics
NPI:1407998271
Name:WAITE, PATRICK L (DDS)
Entity Type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:L
Last Name:WAITE
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 1:4101 CLOCK TOWER AVE
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83607
Mailing Address - Country:US
Mailing Address - Phone:208-455-0022
Mailing Address - Fax:
Practice Address - Street 1:4101 CLOCK TOWER AVE
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83607
Practice Address - Country:US
Practice Address - Phone:208-455-0022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2017-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD39751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807500200Medicaid