Provider Demographics
NPI:1962622142
Name:WAKHAM, MARLON DEAN (DMD)
Entity type:Individual
Prefix:DR
First Name:MARLON
Middle Name:DEAN
Last Name:WAKHAM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 BERTUCCI BLVD.
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39531
Mailing Address - Country:US
Mailing Address - Phone:228-388-5954
Mailing Address - Fax:228-388-5922
Practice Address - Street 1:408 BERTUCCI BLVD
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39531-2339
Practice Address - Country:US
Practice Address - Phone:228-388-5954
Practice Address - Fax:228-388-5922
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOR 260 941223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics