Provider Demographics
NPI:1467788240
Name:SUERO-WADE, MAYRA (DDS)
Entity Type:Individual
Prefix:DR
First Name:MAYRA
Middle Name:
Last Name:SUERO-WADE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 CAMERON RD
Mailing Address - Street 2:
Mailing Address - City:SADDLE RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:07458-2944
Mailing Address - Country:US
Mailing Address - Phone:201-825-4554
Mailing Address - Fax:
Practice Address - Street 1:630 W 168TH ST FL 3
Practice Address - Street 2:COLUMBIA UNIVERSITY - DENTCA
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3725
Practice Address - Country:US
Practice Address - Phone:201-825-3073
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-28
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD107751223G0001X
NY0427461223G0001X
NJ22DI016757001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice