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General NPI Number Information
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NPI Number | 1306223888
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Entity Type | Organization
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Legal Business Name | EMERALD COAST PERIODONTICS
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Dates
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Enumeration Date | 05/04/2015
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Last Update Date | 05/04/2015
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Provider Practice Location Address
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Address Line | 719 BAYSHORE DRIVE
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City | NICEVILLE
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State | FL
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Zip | 32578
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Country | US
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Telephone | 850-678-6485
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Fax |
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Provider Business Mailing Address
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Address Line | 719 BAYSHORE DRIVE
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City | NICEVILLE
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State | FL
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Zip | 32578
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PERIODONTIST
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Name | MARTIN M WOOLSEY
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Credential | DDS
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Telephone | 850-678-6485
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | DN21004
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License Number State | FL
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