Healthcare Provider Details

I. General information

NPI: 1972394120
Provider Name (Legal Business Name): WOLCOTT DMD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2025
Last Update Date: 05/16/2025
Certification Date: 05/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1405 S HIAWASSEE RD
ORLANDO FL
32835-5786
US

IV. Provider business mailing address

550 BRICKELL ST SE
PALM BAY FL
32909-4471
US

V. Phone/Fax

Practice location:
  • Phone: 407-294-6009
  • Fax:
Mailing address:
  • Phone: 321-292-4058
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DESTINY WOLCOTT
Title or Position: OWNER
Credential: DMD
Phone: 321-292-4058