Provider Demographics
NPI:1457467524
Name:WAITE, JOHN T (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:T
Last Name:WAITE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:500 S BROAD ST
Mailing Address - Street 2:DENTAL SUITE
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19146-1613
Mailing Address - Country:US
Mailing Address - Phone:215-685-6768
Mailing Address - Fax:215-685-6891
Practice Address - Street 1:4400 HAVERFORD AVE
Practice Address - Street 2:HEALTH CENTER #4
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-1361
Practice Address - Country:US
Practice Address - Phone:215-685-7630
Practice Address - Fax:215-386-4902
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS026358L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAU08075Medicare UPIN