Provider Demographics
NPI:1396965133
Name:PEAVY, WAYNE WINFRED (DDS)
Entity type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:WINFRED
Last Name:PEAVY
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 1:2902 DENTON HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:HALTOM CITY
Mailing Address - State:TX
Mailing Address - Zip Code:76117
Mailing Address - Country:US
Mailing Address - Phone:817-838-7611
Mailing Address - Fax:817-838-8941
Practice Address - Street 1:2902 DENTON HIGHWAY
Practice Address - Street 2:
Practice Address - City:HALTOM CITY
Practice Address - State:TX
Practice Address - Zip Code:76117
Practice Address - Country:US
Practice Address - Phone:817-838-7611
Practice Address - Fax:817-838-8941
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX89901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice