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General NPI Number Information
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NPI Number | 1770634321
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Entity Type | Individual
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Provider Name | MICHELLE MARIE VANDERWAL RDH
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Gender | Female
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Dates
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Enumeration Date | 01/12/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 340 MAGNOLIA CIR BLDG 1465
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City | TYNDALL AFB
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State | FL
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Zip | 32403-5604
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Country | US
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Telephone | 850-283-7574
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Fax |
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Provider Business Mailing Address
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Address Line | 926 LEE CT
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City | PANAMA CITY
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State | FL
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Zip | 32404-9661
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Country | US
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Telephone | 850-215-7585
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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 | 124Q00000X
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Taxonomy Name | Dental Hygienist
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License Number | DH 18089
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License Number State | FL
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