Provider Demographics
NPI:1689016339
Name:WAKIM, ELIZABETH LAGUE (DDS)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:LAGUE
Last Name:WAKIM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:ELIZABETH
Other - Middle Name:ANTOINETTE
Other - Last Name:LAGUE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:107 NEW CASTLE DR
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26508-4261
Mailing Address - Country:US
Mailing Address - Phone:414-467-7368
Mailing Address - Fax:
Practice Address - Street 1:234 COURT ST
Practice Address - Street 2:
Practice Address - City:CLARKSBURG
Practice Address - State:WV
Practice Address - Zip Code:26301-2906
Practice Address - Country:US
Practice Address - Phone:304-623-4984
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-23
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV40751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice