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General NPI Number Information
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NPI Number | 1578823993
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Entity Type | Individual
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Provider Name | MICHAEL JOHN WIERENGA D.D.S.
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Gender | Male
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Dates
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Enumeration Date | 05/18/2012
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Last Update Date | 05/18/2012
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Provider Practice Location Address
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Address Line | 4320 44TH ST SW STE 106
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City | GRANDVILLE
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State | MI
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Zip | 49418-2300
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Country | US
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Telephone | 616-530-2200
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Fax | 616-530-8250
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Provider Business Mailing Address
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Address Line | 185 LAKE VILLAGE DR APT 203
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City | ANN ARBOR
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State | MI
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Zip | 48103-6539
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Country | US
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Telephone | 616-723-6762
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 2901020644
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License Number State | MI
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