Provider Demographics
NPI:1992854376
Name:WINGATE, MARK WADE (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:WADE
Last Name:WINGATE
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 1:5001 LAKEWOOD DRIVE
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-2920
Mailing Address - Country:US
Mailing Address - Phone:254-772-0180
Mailing Address - Fax:254-772-0181
Practice Address - Street 1:5001 LAKEWOOD DRIVE
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-2920
Practice Address - Country:US
Practice Address - Phone:254-772-0180
Practice Address - Fax:254-772-0181
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16407122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXBCBSD16407OtherBCBS