Provider Demographics
NPI:1891952891
Name:WAYNE PUNDT DDS
Entity Type:Organization
Organization Name:WAYNE PUNDT DDS
Other - Org Name:PUNDT FAMILY DENTISTRY
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:E
Authorized Official - Last Name:PUNDT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:254-634-0234
Mailing Address - Street 1:421 N 38TH ST
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76543-4153
Mailing Address - Country:US
Mailing Address - Phone:254-634-0234
Mailing Address - Fax:
Practice Address - Street 1:421 N 38TH ST
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76543-4153
Practice Address - Country:US
Practice Address - Phone:254-634-0234
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-19
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX102251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX814-402OtherUNITED CONCORDIA PROVIDER ID
TXG60415-01OtherDELTA DENTAL CHIPS PROGRAM