Provider Demographics
NPI:1861600330
Name:SPECTOR, WAYNE JULIAN (DMD)
Entity type:Individual
Prefix:
First Name:WAYNE
Middle Name:JULIAN
Last Name:SPECTOR
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4591
Mailing Address - Street 2:
Mailing Address - City:KETCHUM
Mailing Address - State:ID
Mailing Address - Zip Code:83340-4591
Mailing Address - Country:US
Mailing Address - Phone:208-726-7559
Mailing Address - Fax:
Practice Address - Street 1:680 2ND AVE. NORTH
Practice Address - Street 2:
Practice Address - City:KETCHUM
Practice Address - State:ID
Practice Address - Zip Code:83340
Practice Address - Country:US
Practice Address - Phone:208-726-7559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-17621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDCS4867OtherID STATE BOARD OF PHARMAC
IDD-1762OtherID STATE BOARD OF DENTIST