Provider Demographics
NPI:1477834240
Name:WAITE, ODIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:ODIN
Middle Name:
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 1:1425 N MCLEAN BLVD
Mailing Address - Street 2:STE 200
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123-5702
Mailing Address - Country:US
Mailing Address - Phone:847-697-6868
Mailing Address - Fax:847-697-8355
Practice Address - Street 1:1425 N MCLEAN BLVD STE 200
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123
Practice Address - Country:US
Practice Address - Phone:847-697-6868
Practice Address - Fax:847-697-8355
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-07
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0210028441223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty