1912165556 NPI number — MISS MICHEL MARIE WICKSALL DDS

Table of content: MISS MICHEL MARIE WICKSALL DDS (NPI 1912165556)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912165556 NPI number — MISS MICHEL MARIE WICKSALL DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WICKSALL
Provider First Name:
MICHEL
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1912165556
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/30/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4500 CASCADE RD SE
Provider Second Line Business Mailing Address:
200
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49546
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-975-9700
Provider Business Mailing Address Fax Number:
616-975-9750

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4500 CASCADE RD SE
Provider Second Line Business Practice Location Address:
200
Provider Business Practice Location Address City Name:
GRAND RAPIDS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49546
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-975-9700
Provider Business Practice Location Address Fax Number:
616-975-9750
Provider Enumeration Date:
05/30/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  16961 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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