Provider Demographics
NPI:1104070465
Name:WAYNE DUNETZ DPM PAC LLC
Entity type:Organization
Organization Name:WAYNE DUNETZ DPM PAC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:ADAM
Authorized Official - Last Name:DUNETZ
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:702-821-6763
Mailing Address - Street 1:PO BOX 31327
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89173-1327
Mailing Address - Country:US
Mailing Address - Phone:702-821-6763
Mailing Address - Fax:
Practice Address - Street 1:4450 E WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89110-5783
Practice Address - Country:US
Practice Address - Phone:702-821-6763
Practice Address - Fax:702-684-6015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-12
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV9904213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV6180700001Medicare NSC