Healthcare Provider Details

I. General information

NPI: 1700991940
Provider Name (Legal Business Name): MICHAEL L DEWEERD DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 09/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

879 E SUPERIOR ST
WAYLAND MI
49348-9178
US

IV. Provider business mailing address

879 E SUPERIOR ST
WAYLAND MI
49348-9178
US

V. Phone/Fax

Practice location:
  • Phone: 269-792-2051
  • Fax: 269-792-0772
Mailing address:
  • Phone: 269-792-2051
  • Fax: 269-792-0772

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2901011285
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: