Provider Demographics
NPI:1700819356
Name:GATLIN, WAYNE CHARLES JR
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:CHARLES
Last Name:GATLIN
Suffix:JR
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 1:4220 COLORADO ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55804-1407
Mailing Address - Country:US
Mailing Address - Phone:218-525-3360
Mailing Address - Fax:
Practice Address - Street 1:324 W SUPERIOR ST
Practice Address - Street 2:STE 404
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-1701
Practice Address - Country:US
Practice Address - Phone:218-727-2772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10141MN1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice