Provider Demographics
NPI:1699890863
Name:WAKEFIELD, BRIAN E (DDS)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:E
Last Name:WAKEFIELD
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 1:326 S EDMONDS LN STE 105
Mailing Address - Street 2:SUITE 140
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75067-3507
Mailing Address - Country:US
Mailing Address - Phone:972-221-9334
Mailing Address - Fax:
Practice Address - Street 1:326 S EDMONDS LN STE 105
Practice Address - Street 2:SUITE 140
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75067-3507
Practice Address - Country:US
Practice Address - Phone:972-221-9334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX207381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX010702456OtherTIN