Provider Demographics
NPI:1497894596
Name:WIENS, JONATHAN P (DDS MSD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:P
Last Name:WIENS
Suffix:
Gender:M
Credentials:DDS MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6177 ORCHARD LAKE ROAD
Mailing Address - Street 2:SUITE #120
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322
Mailing Address - Country:US
Mailing Address - Phone:248-855-6655
Mailing Address - Fax:248-855-0803
Practice Address - Street 1:6177 ORCHARD LAKE ROAD
Practice Address - Street 2:SUITE 120
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322
Practice Address - Country:US
Practice Address - Phone:248-855-6655
Practice Address - Fax:248-855-0803
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MID10587122300000X
MI2901010587204E00000X, 1223S0112X, 1223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223P0700XDental ProvidersDentistProsthodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1940814Medicaid
W20350Medicare UPIN
MI5636772Medicare ID - Type Unspecified