MEDICARE: DR. LILY WAKIM DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	00202921	CO

General Provider Information

NPI Number	:	1487101960
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LILY WAKIM DDS

Provider Business Mailing Address
First Line	:	4225 PEBBLE RIDGE CIR APT 62
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80906-6513
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4451 VENETUCCI BLVD STE 160
Second Line	:
City	:	FOUNTAIN
State	:	CO
Zip	:	80906
Country	:	US
Telephone Number	:	719-280-0399
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/01/2016
Last Update Date	:	09/01/2016

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