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General NPI Number Information
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NPI Number | 1255825790
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Entity Type | Individual
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Provider Name | WESLEY ADDISON DENT DMD
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Gender | Male
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Dates
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Enumeration Date | 06/18/2018
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Last Update Date | 06/18/2018
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Provider Practice Location Address
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Address Line | 528 W BALDWIN RD UNIT B
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City | PANAMA CITY
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State | FL
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Zip | 32405-3313
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Country | US
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Telephone | 850-215-0128
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Fax |
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Provider Business Mailing Address
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Address Line | 1508 THURSO RD
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City | LYNN HAVEN
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State | FL
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Zip | 32444-8336
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Country | US
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Telephone | 228-238-3205
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DN23505
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License Number State | FL
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