Provider Demographics
NPI:1568070910
Name:VIERCK, MAKENNA MARIE (DMD)
Entity Type:Individual
Prefix:
First Name:MAKENNA
Middle Name:MARIE
Last Name:VIERCK
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 LYNCH RD
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-9526
Mailing Address - Country:US
Mailing Address - Phone:480-205-9693
Mailing Address - Fax:
Practice Address - Street 1:450 SUTTER ST RM 2320
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94108-4209
Practice Address - Country:US
Practice Address - Phone:425-397-2500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-21
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1050501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice