MEDICARE: SUSAN M WELCH, DDS PA

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	DN15821	FL

General Provider Information

NPI Number	:	1467749309
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUSAN M WELCH, DDS PA

Provider Business Mailing Address
First Line	:	106 WRIGHT PKWY SW
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32548-5208
Country	:	US
Telephone Number	:	850-243-1534
Fax Number	:	850-243-7541

Provider Business Practice Location Address
First Line	:	106 WRIGHT PKWY SW
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32548-5208
Country	:	US
Telephone Number	:	850-243-1534
Fax Number	:	850-243-7541

Authorized Official
Title or Position	:	OWNER/DENTIST
Name	:	DR. SUSAN M WELCH
Credential	:	DDS
Telephone Number	:	850-243-1534

Provider Enumeration Date	:	06/29/2011
Last Update Date	:	06/29/2011

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