Provider Demographics
NPI:1225040140
Name:WISCKOL, RICHARD R (DR)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:R
Last Name:WISCKOL
Suffix:
Gender:M
Credentials:DR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35223 GRAND RIVER
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:48335
Mailing Address - Country:US
Mailing Address - Phone:248-474-4600
Mailing Address - Fax:248-474-0052
Practice Address - Street 1:35223 GRAND RIVER
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MI
Practice Address - Zip Code:48335
Practice Address - Country:US
Practice Address - Phone:248-474-4600
Practice Address - Fax:248-474-0052
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI14482122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
BW0644294OtherDEA REG