Provider Demographics
NPI:1619972668
Name:WAHL, TIMOTHY MICHAEL (DMD)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:MICHAEL
Last Name:WAHL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 S SYKES CREEK PKWY
Mailing Address - Street 2:STE 2
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32952-3572
Mailing Address - Country:US
Mailing Address - Phone:321-459-0154
Mailing Address - Fax:321-459-0739
Practice Address - Street 1:190 S SYKES CREEK PKWY
Practice Address - Street 2:STE 2
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32952-3572
Practice Address - Country:US
Practice Address - Phone:321-459-0154
Practice Address - Fax:321-459-0739
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN94991223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDN9499OtherSTATE DENTAL LICENSE