Provider Demographics
NPI:1740331925
Name:WAKIM, SAMUEL S (DDS)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:S
Last Name:WAKIM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15150 SHONAN GOLD DR
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-5684
Mailing Address - Country:US
Mailing Address - Phone:530-524-7338
Mailing Address - Fax:
Practice Address - Street 1:1927 S HWY 27
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711
Practice Address - Country:US
Practice Address - Phone:352-432-8269
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40509122300000X
IN12011100A122300000X
TX36188122300000X
FLDN23028122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB40509-01Medicaid