Provider records sourced from NPPES (CMS National Plan & Provider Enumeration System). Data current as of August 10, 2026.
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Theron Waisath, DMD

Individual provider Oral and Maxillofacial Surgery (Dentist) · NPI 1144423963

Theron Waisath, DMD is a Maxillofacial Surgery in Champaign, Illinois. Graduated from Southern Illinois Univ School of Dental Medicine in 2004, 22 years ago. Practices with Affiliates in Oral and Maxillofacial Surgery Ltd, a 2-clinician group and accepts Medicare assignment. Licensed in Illinois and Ohio.

Years since qualifying
22
Trained at
Southern Illinois Univ School of Dental Medicine
Licensed in
IL, OH
In the registry since
2007
Specialties on file
2
What do these letters mean?
DMD — Doctor of Dental Medicine
A dentist. Identical training and licensing to a DDS.

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Practice location Address checks out

3112 Vlg Ofc PL
Champaign, IL 61822-7680
Phone: (217) 351-7111
Fax: (217) 351-7282
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Pin is approximate — placed at the ZIP-code centre, not the exact door.

Specialties & licences

Oral and Maxillofacial Surgery (Dentist) (primary) Taxonomy 1223S0112X · Licence 019.027879 (IL)
Oral & Maxillofacial Surgery (D.M.D.) Taxonomy 204E00000X · Licence 2422 (OH)

Record details

NPI number1144423963
Entity typeIndividual (Type 1)
GenderMale
Credentials DMD
Sole proprietorYes
NPI enumeratedJune 8, 2007
Last updated in NPPESJuly 23, 2009

Medicare enrollment

From the CMS Doctors & Clinicians file — this clinician is enrolled in Medicare.

Medicare specialtyMAXILLOFACIAL SURGERY
Medical schoolSOUTHERN ILLINOIS UNIV SCHOOL OF DENTAL MEDICINE
Graduated 2004 (22 years in practice)
Group practice Affiliates In Oral And Maxillofacial Surgery Ltd — 2 clinicians
Accepts Medicare assignment Yes — accepts the Medicare-approved amount
Practice locations2 on file with Medicare

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