Provider Demographics
NPI:1659865376
Name:ELIZABETH L WAKIM DDS LLC
Entity Type:Organization
Organization Name:ELIZABETH L WAKIM DDS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:L
Authorized Official - Last Name:WAKIM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:724-225-5070
Mailing Address - Street 1:604 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:15301-3912
Mailing Address - Country:US
Mailing Address - Phone:724-225-5070
Mailing Address - Fax:724-225-5262
Practice Address - Street 1:604 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:PA
Practice Address - Zip Code:15301-3912
Practice Address - Country:US
Practice Address - Phone:724-225-5070
Practice Address - Fax:724-225-5262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-16
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1030002210001Medicaid