Provider Demographics
NPI:1720385461
Name:WAGLE, ELKE M
Entity Type:Individual
Prefix:
First Name:ELKE
Middle Name:M
Last Name:WAGLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 LONGWOOD AVE
Mailing Address - Street 2:HUNNEWELL BUILDING 4TH FLOOR
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-5724
Mailing Address - Country:US
Mailing Address - Phone:617-355-6571
Mailing Address - Fax:617-730-0478
Practice Address - Street 1:300 LONGWOOD AVE
Practice Address - Street 2:HUNNEWELL BUILDING 4TH FLOOR
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5724
Practice Address - Country:US
Practice Address - Phone:617-355-6571
Practice Address - Fax:617-730-0478
Is Sole Proprietor?:No
Enumeration Date:2011-02-15
Last Update Date:2011-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADL109331223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry