=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306982848
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAVID PETE WINDHAM DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/30/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5701 HICKORY ST
-----------------------------------------------------
City | PANAMA CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32404-7814
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-763-8030
-----------------------------------------------------
Fax | 850-763-0820
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5701 HICKORY ST
-----------------------------------------------------
City | PANAMA CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32404-7814
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-763-8030
-----------------------------------------------------
Fax | 850-763-0820
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 10200
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------