Healthcare Provider Details

I. General information

NPI: 1134307275
Provider Name (Legal Business Name): WENDY SUE WHITE DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: WENDY SUE WIDMAYER DDS

II. Dates (important events)

Enumeration Date: 01/31/2008
Last Update Date: 01/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37304 KINGS HIGHWAY
BEAVER ISLAND MI
49782-0218
US

IV. Provider business mailing address

PO BOX 218
BEAVER ISLAND MI
49782-0218
US

V. Phone/Fax

Practice location:
  • Phone: 231-448-2100
  • Fax: 231-448-2200
Mailing address:
  • Phone: 231-448-2100
  • Fax: 231-448-2200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901016826
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: