MEDICARE: DR. MICHAEL J WINE DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	1325	WY
2	122300000X	Dentist	D 4424	ID

General Provider Information

NPI Number	:	1245353168
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL J WINE DDS

Provider Business Mailing Address
First Line	:	6797 SHIRE RIDGE DR
Second Line	:
City	:	VICTOR
State	:	ID
Zip	:	83455-5036
Country	:	US
Telephone Number	:	614-648-6657
Fax Number	:

Provider Business Practice Location Address
First Line	:	610 W BROADWAY AVE
Second Line	:
City	:	JACKSON
State	:	WY
Zip	:	83001-8213
Country	:	US
Telephone Number	:	307-732-2273
Fax Number	:	307-732-1660

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/07/2007
Last Update Date	:	09/01/2016

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