Healthcare Provider Details

I. General information

NPI: 1871544320
Provider Name (Legal Business Name): DONALD JAY WICKSTRA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3494 LINCOLN RD
HAMILTON MI
49419-9512
US

IV. Provider business mailing address

4023 134TH AVE
HAMILTON MI
49419-9564
US

V. Phone/Fax

Practice location:
  • Phone: 269-751-4601
  • Fax: 269-751-4522
Mailing address:
  • Phone: 269-751-4601
  • Fax: 269-751-4522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12270
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: