Provider Demographics
NPI:1073708368
Name:WISNOSKI, MICHAEL JAMES (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JAMES
Last Name:WISNOSKI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1819 BROADWAY ST STE 105
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77581-5671
Mailing Address - Country:US
Mailing Address - Phone:281-648-4000
Mailing Address - Fax:281-648-4001
Practice Address - Street 1:1819 BROADWAY ST STE 105
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77581-5671
Practice Address - Country:US
Practice Address - Phone:281-648-4000
Practice Address - Fax:281-648-4001
Is Sole Proprietor?:No
Enumeration Date:2007-09-10
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX190571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice