Provider Demographics
NPI:1326100611
Name:WEINER, SAMUEL P (DDS)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:P
Last Name:WEINER
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 1:8547 HENDRIE BLVD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48070-1617
Mailing Address - Country:US
Mailing Address - Phone:586-491-6482
Mailing Address - Fax:
Practice Address - Street 1:69089 N MAIN ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:MI
Practice Address - Zip Code:48062-1146
Practice Address - Country:US
Practice Address - Phone:586-727-5865
Practice Address - Fax:586-727-8429
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901007772122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2901007772OtherPERMANENT DENTAL LIC.
MI3478902Medicaid