Provider Demographics
NPI:1659311678
Name:PAYNE, WAYNE FRANK (DDS)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:FRANK
Last Name:PAYNE
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 1:1619 N GREENWOOD ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-2644
Mailing Address - Country:US
Mailing Address - Phone:719-542-4546
Mailing Address - Fax:719-542-4548
Practice Address - Street 1:1619 N GREENWOOD ST
Practice Address - Street 2:SUITE 102
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-2644
Practice Address - Country:US
Practice Address - Phone:719-542-4546
Practice Address - Fax:719-542-4548
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO05771223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO02005775Medicaid
CO02005775Medicaid
COU03343Medicare UPIN