Healthcare Provider Details

I. General information

NPI: 1013021989
Provider Name (Legal Business Name): CHRISTOPHER B. WILEY D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 10/11/2022
Certification Date: 10/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6515 BLUE STAR HIGHWAY
SAUGATUCK MI
49453-1108
US

IV. Provider business mailing address

PO BOX 1108
SAUGATUCK MI
49453-1108
US

V. Phone/Fax

Practice location:
  • Phone: 269-857-1496
  • Fax: 269-857-4791
Mailing address:
  • Phone: 269-857-1496
  • Fax: 269-857-1497

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number143490
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number143490
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: