MEDICARE: SANTA ROSA BCH DENTAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	DN15518	FL

General Provider Information

NPI Number	:	1023289568
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SANTA ROSA BCH DENTAL

Provider Business Mailing Address
First Line	:	4942 HWY 98 W #19
Second Line	:
City	:	SANTA ROSA BCH
State	:	FL
Zip	:	32459
Country	:	US
Telephone Number	:	850-267-0777
Fax Number	:	850-267-3310

Provider Business Practice Location Address
First Line	:	4942 HWY 98 W #19
Second Line	:
City	:	SANTA ROSA BCH
State	:	FL
Zip	:	32459
Country	:	US
Telephone Number	:	850-267-0777
Fax Number	:	850-267-3310

Authorized Official
Title or Position	:	DENTIST OWNER
Name	:	DR. AMBER E WIEHE
Credential	:	DMD
Telephone Number	:	850-267-0777

Provider Enumeration Date	:	03/12/2008
Last Update Date	:	03/12/2008

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