Provider Demographics
NPI:1790839587
Name:WIECZOREK, KENNETH B (DMD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:B
Last Name:WIECZOREK
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 1:1220 OLD YORK ROAD
Mailing Address - Street 2:
Mailing Address - City:WARMINSTER
Mailing Address - State:PA
Mailing Address - Zip Code:18974
Mailing Address - Country:US
Mailing Address - Phone:215-672-5320
Mailing Address - Fax:215-672-1874
Practice Address - Street 1:1220 OLD YORK ROAD
Practice Address - Street 2:
Practice Address - City:WARMINSTER
Practice Address - State:PA
Practice Address - Zip Code:18974
Practice Address - Country:US
Practice Address - Phone:215-672-5320
Practice Address - Fax:215-672-1874
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS035387L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist