Healthcare Provider Details

I. General information

NPI: 1619972668
Provider Name (Legal Business Name): TIMOTHY MICHAEL WAHL D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 S SYKES CREEK PKWY STE 2
MERRITT ISLAND FL
32952-3572
US

IV. Provider business mailing address

190 S SYKES CREEK PKWY STE 2
MERRITT ISLAND FL
32952-3572
US

V. Phone/Fax

Practice location:
  • Phone: 321-459-0154
  • Fax: 321-459-0739
Mailing address:
  • Phone: 321-459-0154
  • Fax: 321-459-0739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDN9499
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: