Provider Demographics
NPI:1902948060
Name:WADE, ALEX GARDNER (DDS)
Entity Type:Individual
Prefix:DR
First Name:ALEX
Middle Name:GARDNER
Last Name:WADE
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 1:560 W 43RD ST
Mailing Address - Street 2:APT.35C
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10036-4300
Mailing Address - Country:US
Mailing Address - Phone:917-657-5233
Mailing Address - Fax:
Practice Address - Street 1:9828 BLUEBONNET SOUTH
Practice Address - Street 2:SUITE D
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70810
Practice Address - Country:US
Practice Address - Phone:225-752-3407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA55271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice