Provider Demographics
NPI:1528040078
Name:WIENER, MICHAEL A (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:A
Last Name:WIENER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 ST RT 37
Mailing Address - Street 2:SAINT REGIS MOHAWK HEALTH SERVICES DENTAL
Mailing Address - City:AKWESASNE
Mailing Address - State:NY
Mailing Address - Zip Code:13655-2277
Mailing Address - Country:US
Mailing Address - Phone:518-358-3141
Mailing Address - Fax:518-358-2797
Practice Address - Street 1:412 ST RT 37
Practice Address - Street 2:SAINT REGIS MOHAWK HEALTH SERVICES DENTAL
Practice Address - City:AKWESASNE
Practice Address - State:NY
Practice Address - Zip Code:13655-2277
Practice Address - Country:US
Practice Address - Phone:518-358-3141
Practice Address - Fax:518-358-2797
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051643122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist