Healthcare Provider Details

I. General information

NPI: 1154524817
Provider Name (Legal Business Name): MICHAEL R WIESNER D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2007
Last Update Date: 03/11/2025
Certification Date: 03/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

385 BERT KOUNS LOOP STE 700
SHREVEPORT LA
71106-8163
US

IV. Provider business mailing address

385 BERT KOUNS LOOP STE 700
SHREVEPORT LA
71106-8163
US

V. Phone/Fax

Practice location:
  • Phone: 318-688-9330
  • Fax:
Mailing address:
  • Phone: 318-779-1254
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number5831
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5831
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: