Provider Demographics
NPI:1750495743
Name:E. MARK WADE DDSPC
Entity type:Organization
Organization Name:E. MARK WADE DDSPC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:E
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:WADE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:480-926-7363
Mailing Address - Street 1:1121 S GILBERT RD
Mailing Address - Street 2:#104
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85204-5235
Mailing Address - Country:US
Mailing Address - Phone:480-926-7363
Mailing Address - Fax:480-926-7365
Practice Address - Street 1:1121 S GILBERT RD
Practice Address - Street 2:#104
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-5235
Practice Address - Country:US
Practice Address - Phone:480-926-7363
Practice Address - Fax:480-926-7365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ32771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty