Provider Demographics
NPI:1073059168
Name:WIERZBICKI, JERZY
Entity Type:Individual
Prefix:
First Name:JERZY
Middle Name:
Last Name:WIERZBICKI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2117 GLENHOLLOW ST
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91361-2023
Mailing Address - Country:US
Mailing Address - Phone:213-519-1548
Mailing Address - Fax:
Practice Address - Street 1:6040 PACIFIC BLVD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-2931
Practice Address - Country:US
Practice Address - Phone:323-583-5677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-12
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35358122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist