Healthcare Provider Details

I. General information

NPI: 1528040078
Provider Name (Legal Business Name): MICHAEL A WIENER DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/18/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 ST RT 37 SAINT REGIS MOHAWK HEALTH SERVICES DENTAL
AKWESASNE NY
13655-2277
US

IV. Provider business mailing address

412 ST RT 37 SAINT REGIS MOHAWK HEALTH SERVICES DENTAL
AKWESASNE NY
13655-2277
US

V. Phone/Fax

Practice location:
  • Phone: 518-358-3141
  • Fax: 518-358-2797
Mailing address:
  • Phone: 518-358-3141
  • Fax: 518-358-2797

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number051643
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: