Provider Demographics
NPI:1659599413
Name:LARIVIERE, WAYNE (DMD)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:
Last Name:LARIVIERE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 378
Mailing Address - Street 2:
Mailing Address - City:WATERBORO
Mailing Address - State:ME
Mailing Address - Zip Code:04087-0378
Mailing Address - Country:US
Mailing Address - Phone:207-247-3511
Mailing Address - Fax:207-247-3533
Practice Address - Street 1:813 MAIN ST
Practice Address - Street 2:B
Practice Address - City:WATERBORO
Practice Address - State:ME
Practice Address - Zip Code:04087-3006
Practice Address - Country:US
Practice Address - Phone:207-247-3511
Practice Address - Fax:207-247-3533
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME28211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice