Provider Demographics
NPI:1235245671
Name:WAKIM, JOHN E (DMD PC)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:E
Last Name:WAKIM
Suffix:
Gender:M
Credentials:DMD PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 BROOKVIEW COURT
Mailing Address - Street 2:
Mailing Address - City:NOANK
Mailing Address - State:CT
Mailing Address - Zip Code:06340
Mailing Address - Country:US
Mailing Address - Phone:860-536-7527
Mailing Address - Fax:
Practice Address - Street 1:743 LONG HILL ROAD
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340
Practice Address - Country:US
Practice Address - Phone:860-445-9520
Practice Address - Fax:860-445-5901
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5048122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist