Provider Demographics
NPI:1982860854
Name:WAKEFIELD, CHARLES WILLIAM (DDS)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:WILLIAM
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
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75067-3580
Mailing Address - Country:US
Mailing Address - Phone:972-221-9334
Mailing Address - Fax:972-436-7130
Practice Address - Street 1:326 S EDMONDS LN
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75067-3580
Practice Address - Country:US
Practice Address - Phone:972-221-9334
Practice Address - Fax:972-436-7130
Is Sole Proprietor?:No
Enumeration Date:2008-07-31
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX183991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice