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General NPI Number Information
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NPI Number | 1619972668
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Entity Type | Individual
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Provider Name | TIMOTHY MICHAEL WAHL D.M.D.
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Gender | Male
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Dates
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Enumeration Date | 06/16/2005
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 190 S SYKES CREEK PKWY STE 2
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City | MERRITT ISLAND
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State | FL
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Zip | 32952-3572
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Country | US
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Telephone | 321-459-0154
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Fax | 321-459-0739
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Provider Business Mailing Address
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Address Line | 190 S SYKES CREEK PKWY STE 2
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City | MERRITT ISLAND
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State | FL
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Zip | 32952-3572
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Country | US
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Telephone | 321-459-0154
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Fax | 321-459-0739
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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 | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | DN9499
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License Number State | FL
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