Healthcare Provider Details

I. General information

NPI: 1780106070
Provider Name (Legal Business Name): KELSEY WAHL DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2017
Last Update Date: 10/07/2022
Certification Date: 10/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 CARDINAL POINT DR
JACKSONVILLE FL
32257-5581
US

IV. Provider business mailing address

3600 CARDINAL POINT DR
JACKSONVILLE FL
32257-5581
US

V. Phone/Fax

Practice location:
  • Phone: 904-737-4626
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number22605
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: