Provider Demographics
NPI:1356658348
Name:WEISNER, MICHAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:WEISNER
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 1:130 BOWDOIN ST APT 1404
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02108-2722
Mailing Address - Country:US
Mailing Address - Phone:978-509-8125
Mailing Address - Fax:
Practice Address - Street 1:130 BOWDOIN ST APT 1404
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02108-2722
Practice Address - Country:US
Practice Address - Phone:978-509-8125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-12
Last Update Date:2010-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18555251223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics