Provider Demographics
NPI:1912029869
Name:LIUDAHL, WAYNE REUBEN (DDS)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:REUBEN
Last Name:LIUDAHL
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 1:4805 W CENTRAL
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67212
Mailing Address - Country:US
Mailing Address - Phone:316-945-9845
Mailing Address - Fax:316-945-3164
Practice Address - Street 1:4805 W CENTRAL
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67212
Practice Address - Country:US
Practice Address - Phone:316-945-9845
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS5312122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist