Healthcare Provider Details

I. General information

NPI: 1780750570
Provider Name (Legal Business Name): CANDACE THERESE WAKEFIELD D.M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10166 W FLORISSANT AVE
SAINT LOUIS MO
63136-2104
US

IV. Provider business mailing address

1611 LOCUST ST UNIT 501
SAINT LOUIS MO
63103-1857
US

V. Phone/Fax

Practice location:
  • Phone: 314-867-5650
  • Fax: 314-867-5652
Mailing address:
  • Phone: 314-588-1519
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number2000175293
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: