Provider Demographics
NPI:1437428521
Name:HAWKS, WAYNE R (DMD)
Entity Type:Individual
Prefix:MR
First Name:WAYNE
Middle Name:R
Last Name:HAWKS
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 1:3015 S PROVIDENCE RD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-3670
Mailing Address - Country:US
Mailing Address - Phone:573-449-2941
Mailing Address - Fax:573-443-3427
Practice Address - Street 1:3015 S PROVIDENCE RD
Practice Address - Street 2:SUITE 4
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-3670
Practice Address - Country:US
Practice Address - Phone:573-449-2941
Practice Address - Fax:573-443-3427
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-20
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0113121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO$$$$$$$$$AOtherMEDICARE