MEDICARE: DR. CANDACE THERESE WAKEFIELD D.M.D

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	1223P0221X	Pediatric Dentistry	2000175293	MO

General Provider Information

NPI Number	:	1780750570
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CANDACE THERESE WAKEFIELD D.M.D

Provider Business Mailing Address
First Line	:	1611 LOCUST ST
Second Line	:	UNIT 501
City	:	SAINT LOUIS
State	:	MO
Zip	:	63103-1857
Country	:	US
Telephone Number	:	314-588-1519
Fax Number	:

Provider Business Practice Location Address
First Line	:	10166 W FLORISSANT AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63136-2104
Country	:	US
Telephone Number	:	314-867-5650
Fax Number	:	314-867-5652

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

Provider Enumeration Date	:	11/26/2006
Last Update Date	:	07/08/2007

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