Healthcare Provider Details

I. General information

NPI: 1124157003
Provider Name (Legal Business Name): ROBERT K. WESLEY D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36590 HERITAGE DR
RICHMOND MI
48062-1936
US

IV. Provider business mailing address

4956 BOWMAN RD
SAINT CLAIR MI
48079-3400
US

V. Phone/Fax

Practice location:
  • Phone: 586-727-3838
  • Fax: 586-727-3833
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2901017425
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: