Provider Demographics
NPI:1437248036
Name:WIRTH, MICHAEL JAY (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JAY
Last Name:WIRTH
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 1:1029 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50702-2803
Mailing Address - Country:US
Mailing Address - Phone:319-235-0361
Mailing Address - Fax:319-235-0362
Practice Address - Street 1:1029 W 4TH ST
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50702-2803
Practice Address - Country:US
Practice Address - Phone:319-235-0361
Practice Address - Fax:319-235-0362
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA067161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice