Healthcare Provider Details

I. General information

NPI: 1750495149
Provider Name (Legal Business Name): MARIELSA ADRIANZA ADRIANZA-WEIDANZ DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 08/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 S FERDON BLVD SUITE C2
CRESTVIEW FL
32536-5252
US

IV. Provider business mailing address

2804 REMINGTON GREEN CIR STE 2
TALLAHASSEE FL
32308-1550
US

V. Phone/Fax

Practice location:
  • Phone: 850-423-4603
  • Fax: 850-423-0473
Mailing address:
  • Phone: 850-385-4494
  • Fax: 850-298-6054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number20288
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number13927
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN14799
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: