Healthcare Provider Details

I. General information

NPI: 1235127036
Provider Name (Legal Business Name): JOHN SCOTT WIENCEK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/06/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 E WASHINGTON ST
STOUGHTON WI
53589-1736
US

IV. Provider business mailing address

114 E WASHINGTON ST
STOUGHTON WI
53589-1736
US

V. Phone/Fax

Practice location:
  • Phone: 608-873-7412
  • Fax: 608-873-7342
Mailing address:
  • Phone: 608-873-7412
  • Fax: 608-873-7342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number3244015
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: