MEDICARE: ALAN DIEP DMD

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	1223G0001X	General Practice Dentistry	27317	FL

General Provider Information

NPI Number	:	1245968981
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALAN DIEP DMD

Provider Business Mailing Address
First Line	:	200 MC DAVIS LOOP UNIT 3106
Second Line	:
City	:	SANTA ROSA BEACH
State	:	FL
Zip	:	32459-6787
Country	:	US
Telephone Number	:	281-777-2856
Fax Number	:

Provider Business Practice Location Address
First Line	:	528 W BALDWIN RD UNIT B
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32405-3313
Country	:	US
Telephone Number	:	850-215-0128
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/10/2022
Last Update Date	:	08/10/2022

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