Provider Demographics
NPI:1679633432
Name:WICENSKI, BRIAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:
Last Name:WICENSKI
Suffix:
Gender:M
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:PO BOX 1017
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:NH
Mailing Address - Zip Code:03257-1017
Mailing Address - Country:US
Mailing Address - Phone:603-526-9311
Mailing Address - Fax:
Practice Address - Street 1:27 NEWPORT ROAD
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:NH
Practice Address - Zip Code:03257-1017
Practice Address - Country:US
Practice Address - Phone:603-526-2286
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH30191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice