Provider Demographics
NPI:1023289568
Name:SANTA ROSA BCH DENTAL
Entity type:Organization
Organization Name:SANTA ROSA BCH DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:E
Authorized Official - Last Name:WIEHE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:850-267-0777
Mailing Address - Street 1:4942 HWY 98 W #19
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA BCH
Mailing Address - State:FL
Mailing Address - Zip Code:32459
Mailing Address - Country:US
Mailing Address - Phone:850-267-0777
Mailing Address - Fax:850-267-3310
Practice Address - Street 1:4942 HWY 98 W #19
Practice Address - Street 2:
Practice Address - City:SANTA ROSA BCH
Practice Address - State:FL
Practice Address - Zip Code:32459
Practice Address - Country:US
Practice Address - Phone:850-267-0777
Practice Address - Fax:850-267-3310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-12
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN15518122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty