Provider Demographics
NPI:1952803504
Name:DR. ODIN WAITE, P.C.
Entity Type:Organization
Organization Name:DR. ODIN WAITE, P.C.
Other - Org Name:ELGIN ORAL AND MAXILLOFACIAL SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WAITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-697-6868
Mailing Address - Street 1:1425 N MCLEAN BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123-5702
Mailing Address - Country:US
Mailing Address - Phone:847-697-6868
Mailing Address - Fax:
Practice Address - Street 1:1425 N MCLEAN BLVD STE 200
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123
Practice Address - Country:US
Practice Address - Phone:847-697-6868
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-28
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL021.0028441223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty