Provider Demographics
NPI:1528170867
Name:OSTDICK, WAYNE W (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:W
Last Name:OSTDICK
Suffix:
Gender:M
Credentials:DDS, MS
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 82
Mailing Address - Street 2:
Mailing Address - City:SUSSEX
Mailing Address - State:WI
Mailing Address - Zip Code:53089-0082
Mailing Address - Country:US
Mailing Address - Phone:262-820-0825
Mailing Address - Fax:
Practice Address - Street 1:N64W24050 MAIN ST
Practice Address - Street 2:SUITE 200
Practice Address - City:SUSSEX
Practice Address - State:WI
Practice Address - Zip Code:53089-3071
Practice Address - Country:US
Practice Address - Phone:262-820-0825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIWI 45561223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIWI 4556OtherDENTIST LICENSE NUMBER