Healthcare Provider Details

I. General information

NPI: 1053984591
Provider Name (Legal Business Name): MICHEL MARIE WICKSALL DDS PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2021
Last Update Date: 07/22/2021
Certification Date: 07/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4880 CASCADE RD SE STE B
GRAND RAPIDS MI
49546-3701
US

IV. Provider business mailing address

4880 CASCADE RD SE STE B
GRAND RAPIDS MI
49546-3701
US

V. Phone/Fax

Practice location:
  • Phone: 616-975-9700
  • Fax: 616-975-9750
Mailing address:
  • Phone: 616-975-9700
  • Fax: 616-975-9750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MS. MICHEL WICKSALL
Title or Position: OWNER
Credential:
Phone: 616-975-9700