Provider Demographics
NPI:1720470990
Name:ENDO, WAYNE
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:
Last Name:ENDO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9421 244TH ST SW APT AG201
Mailing Address - Street 2:
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98020-7525
Mailing Address - Country:US
Mailing Address - Phone:206-250-4178
Mailing Address - Fax:
Practice Address - Street 1:8532 122ND AVE NE
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98033-5831
Practice Address - Country:US
Practice Address - Phone:206-250-4178
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-25
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADH60299399124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist