Provider Demographics
NPI:1700279437
Name:KRISTIN M WADE DMD PLLC
Entity Type:Organization
Organization Name:KRISTIN M WADE DMD PLLC
Other - Org Name:PAYSON PREMIER DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:MELISSA
Authorized Official - Last Name:WADE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:928-472-8400
Mailing Address - Street 1:409 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PAYSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85541-5487
Mailing Address - Country:US
Mailing Address - Phone:928-472-8400
Mailing Address - Fax:928-472-8300
Practice Address - Street 1:409 W MAIN ST
Practice Address - Street 2:
Practice Address - City:PAYSON
Practice Address - State:AZ
Practice Address - Zip Code:85541-5487
Practice Address - Country:US
Practice Address - Phone:928-472-8400
Practice Address - Fax:928-472-8300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-04
Last Update Date:2015-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD78221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty