=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669119152
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK JOHN WIERENGA DDS, MS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2022
-----------------------------------------------------
Last Update Date | 05/16/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3131 44TH ST SW
-----------------------------------------------------
City | GRANDVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49418-2684
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-301-8900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4421 PENNY LN SW
-----------------------------------------------------
City | WYOMING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49418-9383
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-862-8202
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 2901020872
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------