Provider Demographics
NPI:1750301594
Name:WESLEY, RICHARD K (DDS)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:K
Last Name:WESLEY
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 1:19251 MACK AVE
Mailing Address - Street 2:STE 70LL
Mailing Address - City:GROSS POINTE WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48236
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19251 MACK AVE
Practice Address - Street 2:STE 70LL
Practice Address - City:GROSS POINTE WOODS
Practice Address - State:MI
Practice Address - Zip Code:48236
Practice Address - Country:US
Practice Address - Phone:313-343-4087
Practice Address - Fax:313-343-7842
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901010585122300000X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
T34449Medicare UPIN