Provider Demographics
NPI:1700172806
Name:CHILDREN'S DENTAL ZONE
Entity Type:Organization
Organization Name:CHILDREN'S DENTAL ZONE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:CANDACE
Authorized Official - Middle Name:THERESE
Authorized Official - Last Name:WAKEFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:314-830-9663
Mailing Address - Street 1:13410 NEW HALLS FERRY RD
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63033-3035
Mailing Address - Country:US
Mailing Address - Phone:314-830-9663
Mailing Address - Fax:314-830-9664
Practice Address - Street 1:13410 NEW HALLS FERRY RD
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63033-3035
Practice Address - Country:US
Practice Address - Phone:314-830-9663
Practice Address - Fax:314-830-9664
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-27
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000175293261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental