Provider Demographics
NPI:1659481059
Name:ANDERSON, WAYNE CLARK (DDS)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:CLARK
Last Name:ANDERSON
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 1:200 DOCTORS DRIVE
Mailing Address - Street 2:SUITE F
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546
Mailing Address - Country:US
Mailing Address - Phone:910-353-4242
Mailing Address - Fax:910-577-6421
Practice Address - Street 1:200 DOCTORS DRIVE
Practice Address - Street 2:SUITE F
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546
Practice Address - Country:US
Practice Address - Phone:910-353-4242
Practice Address - Fax:910-577-6421
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC29961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC02211OtherBCBS
NC8990244Medicaid
NC2996OtherDELTA
NC02211OtherBCBS