Healthcare Provider Details

I. General information

NPI: 1639193915
Provider Name (Legal Business Name): JEFFREY L WASIELEWSKI D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 07/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9416 S MAIN ST STE 211
PLYMOUTH MI
48170-4157
US

IV. Provider business mailing address

9416 S MAIN ST STE 211
PLYMOUTH MI
48170-4183
US

V. Phone/Fax

Practice location:
  • Phone: 734-455-0710
  • Fax: 734-455-4433
Mailing address:
  • Phone: 734-478-0329
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number2901017635
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2901017635
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: