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NPI Code Detail

MEDICARE: DR. DONALD JAY WICKSTRA DDS

MEDICARE: DR. DONALD JAY WICKSTRA DDS
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
11223G0001XGeneral Practice Dentistry12270MI

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1871544320
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. DONALD JAY WICKSTRA DDS
Provider Business Mailing Address
First Line : 4023 134TH AVE
Second Line :
City : HAMILTON
State : MI
Zip : 49419-9564
Country : US
Telephone Number : 269-751-4601
Fax Number : 269-751-4522
Provider Business Practice Location Address
First Line : 3494 LINCOLN RD
Second Line :
City : HAMILTON
State : MI
Zip : 49419-9512
Country : US
Telephone Number : 269-751-4601
Fax Number : 269-751-4522
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/12/2006
Last Update Date : 07/09/2007

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