Healthcare Provider Details

I. General information

NPI: 1558682815
Provider Name (Legal Business Name): CARISSA JANE WENTLAND DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2010
Last Update Date: 01/26/2024
Certification Date: 01/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 BEAUBIEN ST # 3515
DETROIT MI
48201-2119
US

IV. Provider business mailing address

3901 BEAUBIEN ST # 3515
DETROIT MI
48201-2119
US

V. Phone/Fax

Practice location:
  • Phone: 313-745-9049
  • Fax: 313-993-3879
Mailing address:
  • Phone: 313-745-9049
  • Fax: 313-993-3879

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number2019020869
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number5101018847
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License Number5101025549
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number01220
License Number StateOH
# 5
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number262814
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: