Provider Demographics
NPI:1275658056
Name:WISNIESKI, GLENN JOHN (DDS)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:JOHN
Last Name:WISNIESKI
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 1:409 ROOSEVELT RD
Mailing Address - Street 2:
Mailing Address - City:WALKERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46574
Mailing Address - Country:US
Mailing Address - Phone:574-586-3242
Mailing Address - Fax:574-686-3242
Practice Address - Street 1:409 ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:WALKERTON
Practice Address - State:IN
Practice Address - Zip Code:46574
Practice Address - Country:US
Practice Address - Phone:574-586-3242
Practice Address - Fax:574-686-3242
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12007003A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice