Provider Demographics
NPI:1598177644
Name:WADAS, JOHN IV
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:WADAS
Suffix:IV
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 RIDGE RD
Mailing Address - Street 2:A
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-1570
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:417 RIDGE RD
Practice Address - Street 2:A
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-1570
Practice Address - Country:US
Practice Address - Phone:219-836-9841
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-23
Last Update Date:2014-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12012110A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist