Healthcare Provider Details

I. General information

NPI: 1710093992
Provider Name (Legal Business Name): ALPHA OMEGA DENTAL CENTER PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 03/03/2024
Certification Date: 03/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1550 COMMERCE DR
MARQUETTE MI
49855-8640
US

IV. Provider business mailing address

1550 COMMERCE DR
MARQUETTE MI
49855-8640
US

V. Phone/Fax

Practice location:
  • Phone: 906-225-1100
  • Fax: 906-225-0889
Mailing address:
  • Phone: 906-225-1100
  • Fax: 906-225-0889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number2901016962
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: DR. CYNTHIA MAE WIGGINS
Title or Position: OWNER - SOLE MEMBER
Credential: DDS
Phone: 906-225-1100