Provider Demographics
NPI:1063526226
Name:REZA, WADUD (DDS)
Entity type:Individual
Prefix:
First Name:WADUD
Middle Name:
Last Name:REZA
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 1:2 BUSINESS PARK CT
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13502-6308
Mailing Address - Country:US
Mailing Address - Phone:315-982-0692
Mailing Address - Fax:315-732-0481
Practice Address - Street 1:2 BUSINESS PARK CT
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-6308
Practice Address - Country:US
Practice Address - Phone:315-982-0692
Practice Address - Fax:315-732-0481
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH207991223G0001X
NY054818122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH20-1660371OtherTAX ID
OH219-0516Medicaid
NY03236220Medicaid