Provider Demographics
NPI:1639193915
Name:WASIELEWSKI, JEFFREY L (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:L
Last Name:WASIELEWSKI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9416 S MAIN ST STE 211
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-4183
Mailing Address - Country:US
Mailing Address - Phone:734-478-0329
Mailing Address - Fax:
Practice Address - Street 1:9416 S MAIN ST
Practice Address - Street 2:STE 211
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-4157
Practice Address - Country:US
Practice Address - Phone:734-455-0710
Practice Address - Fax:734-455-4433
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901017635204E00000X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery