Provider Demographics
NPI:1558922013
Name:WIEJKUS, CAROL WANDA
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:WANDA
Last Name:WIEJKUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 EDEN RD
Mailing Address - Street 2:
Mailing Address - City:MARSHFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:02050-4726
Mailing Address - Country:US
Mailing Address - Phone:781-837-8730
Mailing Address - Fax:
Practice Address - Street 1:4 KEITH WAY STE 3
Practice Address - Street 2:
Practice Address - City:HINGHAM
Practice Address - State:MA
Practice Address - Zip Code:02043-4258
Practice Address - Country:US
Practice Address - Phone:781-608-8838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-25
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADH10489124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist