Provider Demographics
NPI:1578823993
Name:WIERENGA, MICHAEL JOHN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOHN
Last Name:WIERENGA
Suffix:
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 1:185 LAKE VILLAGE DR APT 203
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-6539
Mailing Address - Country:US
Mailing Address - Phone:616-723-6762
Mailing Address - Fax:
Practice Address - Street 1:4320 44TH ST SW
Practice Address - Street 2:STE 106
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-2300
Practice Address - Country:US
Practice Address - Phone:616-530-2200
Practice Address - Fax:616-530-8250
Is Sole Proprietor?:No
Enumeration Date:2012-05-18
Last Update Date:2012-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901020644122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist