Provider Demographics
NPI:1750838397
Name:WIECZERZA, KEVIN GEORGE (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:GEORGE
Last Name:WIECZERZA
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 1:4075 STONE SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-9723
Mailing Address - Country:US
Mailing Address - Phone:734-971-2200
Mailing Address - Fax:734-971-2555
Practice Address - Street 1:4075 STONE SCHOOL RD
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48108-9723
Practice Address - Country:US
Practice Address - Phone:734-971-2200
Practice Address - Fax:734-971-2555
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901022021122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist