Provider Demographics
NPI:1508877432
Name:MONROE, WAYNE CLARK (DDS)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:CLARK
Last Name:MONROE
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 1:204 EAST BRIGGS AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:IA
Mailing Address - Zip Code:52556
Mailing Address - Country:US
Mailing Address - Phone:641-472-5820
Mailing Address - Fax:
Practice Address - Street 1:204 EAST BRIGGS AVE
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:IA
Practice Address - Zip Code:52556
Practice Address - Country:US
Practice Address - Phone:641-472-5820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA06038122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0065813Medicaid