Provider Demographics
NPI:1396856795
Name:WAHL, JANICE G (DMD)
Entity Type:Individual
Prefix:DR
First Name:JANICE
Middle Name:G
Last Name:WAHL
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1061 S WICKHAM RD
Mailing Address - Street 2:
Mailing Address - City:WEST MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-1652
Mailing Address - Country:US
Mailing Address - Phone:321-724-1400
Mailing Address - Fax:321-722-4442
Practice Address - Street 1:1061 S WICKHAM RD
Practice Address - Street 2:
Practice Address - City:WEST MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-1652
Practice Address - Country:US
Practice Address - Phone:321-724-1400
Practice Address - Fax:321-722-4442
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN93481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
593478002OtherTAX ID