Provider Demographics
NPI:1023060498
Name:WAYNE, GARY JON (DMD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:JON
Last Name:WAYNE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 N MILITARY TRL
Mailing Address - Street 2:SUITE 308
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33431-6344
Mailing Address - Country:US
Mailing Address - Phone:561-443-7001
Mailing Address - Fax:
Practice Address - Street 1:2500 N MILITARY TRL
Practice Address - Street 2:SUITE 308
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33431-6344
Practice Address - Country:US
Practice Address - Phone:561-443-7001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN134031223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU51718Medicare UPIN