Provider Demographics
NPI:1487742433
Name:SVOBODA, WAYNE ETNYRE (DDS)
Entity type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:ETNYRE
Last Name:SVOBODA
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 1:32105 1ST AVE S
Mailing Address - Street 2:# B3
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003
Mailing Address - Country:US
Mailing Address - Phone:253-838-2560
Mailing Address - Fax:253-838-2561
Practice Address - Street 1:32105 1ST AVE S
Practice Address - Street 2:# B3
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003
Practice Address - Country:US
Practice Address - Phone:253-838-2560
Practice Address - Fax:253-838-2561
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00006634122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5020227Medicaid
WA601630258OtherUNIFIED BUSINESS ID