Provider Demographics
NPI:1750495149
Name:ADRIANZA-WEIDANZ, MARIELSA ADRIANZA (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARIELSA
Middle Name:ADRIANZA
Last Name:ADRIANZA-WEIDANZ
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2804 REMINGTON GREEN CIR STE 2
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-1550
Mailing Address - Country:US
Mailing Address - Phone:850-385-4494
Mailing Address - Fax:850-298-6054
Practice Address - Street 1:4100 S FERDON BLVD
Practice Address - Street 2:SUITE C2
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-5252
Practice Address - Country:US
Practice Address - Phone:850-423-4603
Practice Address - Fax:850-423-0473
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2013-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX202881223G0001X
TX13927122300000X
FLDN147991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008109700Medicaid