Provider Demographics
NPI:1710093992
Name:ALPHA OMEGA DENTAL CENTER PLLC
Entity Type:Organization
Organization Name:ALPHA OMEGA DENTAL CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER - SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:MAE
Authorized Official - Last Name:WIGGINS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:906-225-1100
Mailing Address - Street 1:1550 COMMERCE DR
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-8640
Mailing Address - Country:US
Mailing Address - Phone:906-225-1100
Mailing Address - Fax:906-225-0889
Practice Address - Street 1:1550 COMMERCE DR
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-8640
Practice Address - Country:US
Practice Address - Phone:906-225-1100
Practice Address - Fax:906-225-0889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2024-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901016962261QD0000X
332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment