Provider Demographics
NPI:1316118284
Name:CHISHOLM, WAYNE R (DDS)
Entity type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:R
Last Name:CHISHOLM
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:PO BOX 69
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:UT
Mailing Address - Zip Code:84754-0069
Mailing Address - Country:US
Mailing Address - Phone:435-527-3555
Mailing Address - Fax:435-527-3618
Practice Address - Street 1:30 SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:UT
Practice Address - Zip Code:84754
Practice Address - Country:US
Practice Address - Phone:435-527-3555
Practice Address - Fax:435-527-3618
Is Sole Proprietor?:No
Enumeration Date:2008-03-18
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1346341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice