Provider Demographics
NPI:1659936441
Name:WDWROSEVILLEPLLC
Entity Type:Organization
Organization Name:WDWROSEVILLEPLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WHITNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:WEINER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-772-0100
Mailing Address - Street 1:21055 E 12 MILE RD
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-2205
Mailing Address - Country:US
Mailing Address - Phone:586-772-0100
Mailing Address - Fax:586-772-3128
Practice Address - Street 1:21055 E 12 MILE RD
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-2205
Practice Address - Country:US
Practice Address - Phone:586-772-0100
Practice Address - Fax:586-772-3128
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WDW VENTURES LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-05-07
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty