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General NPI Number Information
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NPI Number | 1851685226
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Entity Type | Organization
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Legal Business Name | BENJAMIN H. WICKSTRA DDS, PLLC
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Dates
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Enumeration Date | 06/02/2011
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Last Update Date | 06/02/2011
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Provider Practice Location Address
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Address Line | 567 CENTRAL AVE
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City | HOLLAND
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State | MI
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Zip | 49423-4848
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Country | US
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Telephone | 616-218-5795
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Fax |
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Provider Business Mailing Address
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Address Line | 567 CENTRAL AVE
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City | HOLLAND
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State | MI
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Zip | 49423-4848
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Country | US
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Telephone | 616-218-5795
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. BENJAMIN H WICKSTRA
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Credential | D.D.S.
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Telephone | 616-218-5795
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 2901019584
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License Number State | MI
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