Healthcare Provider Details

I. General information

NPI: 1770352346
Provider Name (Legal Business Name): MRA ORTHODONTICS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/25/2023
Last Update Date: 12/25/2023
Certification Date: 12/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12180 S SHORE BLVD STE 101
WELLINGTON FL
33414-6505
US

IV. Provider business mailing address

12180 S SHORE BLVD STE 101
WELLINGTON FL
33414-6505
US

V. Phone/Fax

Practice location:
  • Phone: 561-793-9888
  • Fax:
Mailing address:
  • Phone: 561-793-9888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL WIERNICKI
Title or Position: ORTHODONTIST
Credential: DMD MS
Phone: 561-289-4374