Provider Demographics
NPI:1467462341
Name:WIERSUM, JOEL GREGORY SR (DDS)
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:GREGORY
Last Name:WIERSUM
Suffix:SR
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 1:411 REZANOF DR E
Mailing Address - Street 2:SUITE 101
Mailing Address - City:KODIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99615
Mailing Address - Country:US
Mailing Address - Phone:907-486-3475
Mailing Address - Fax:907-486-3427
Practice Address - Street 1:411 REZANOF DR E
Practice Address - Street 2:SUITE 101
Practice Address - City:KODIAK
Practice Address - State:AK
Practice Address - Zip Code:99615
Practice Address - Country:US
Practice Address - Phone:907-486-3475
Practice Address - Fax:907-486-3427
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKAA799122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKDD0799Medicaid