=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720674559
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WDW EASTPOINTE PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/16/2020
-----------------------------------------------------
Last Update Date | 12/16/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18501 E 8 MILE RD
-----------------------------------------------------
City | EASTPOINTE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48021-3200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-777-0260
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18501 E 8 MILE RD
-----------------------------------------------------
City | EASTPOINTE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48021-3200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-777-0260
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | WHITNEY WEINER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 586-777-0260
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------