Healthcare Provider Details

I. General information

NPI: 1952144529
Provider Name (Legal Business Name): DESTINY FAITH WOLCOTT DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DESTINY FAITH CUNNINGHAM

II. Dates (important events)

Enumeration Date: 06/13/2024
Last Update Date: 06/13/2024
Certification Date: 06/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1890 PALM BAY RD NE STE 2
PALM BAY FL
32905-3071
US

IV. Provider business mailing address

550 BRICKELL ST SE
PALM BAY FL
32909-4471
US

V. Phone/Fax

Practice location:
  • Phone: 321-724-5100
  • Fax:
Mailing address:
  • Phone: 321-292-4058
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number29074
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: