Provider Demographics
NPI:1831199843
Name:WAKSOR, ADAM (DDS)
Entity type:Individual
Prefix:DR
First Name:ADAM
Middle Name:
Last Name:WAKSOR
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 1:1040 EAGLES LANDING PKWY
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-9072
Mailing Address - Country:US
Mailing Address - Phone:678-836-2136
Mailing Address - Fax:
Practice Address - Street 1:1040 EAGLE LNDNG PKWY
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-9072
Practice Address - Country:US
Practice Address - Phone:917-922-2750
Practice Address - Fax:678-289-8560
Is Sole Proprietor?:No
Enumeration Date:2005-08-01
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047013-11223S0112X
GADN0142341223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02348781Medicaid