Provider Demographics
NPI:1790963312
Name:PHILLIP A WIENCZEWSKI PLLC
Entity Type:Organization
Organization Name:PHILLIP A WIENCZEWSKI PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:WIENCZEWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:989-984-0560
Mailing Address - Street 1:671 E M 55
Mailing Address - Street 2:
Mailing Address - City:TAWAS CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48763
Mailing Address - Country:US
Mailing Address - Phone:989-984-0560
Mailing Address - Fax:989-984-0562
Practice Address - Street 1:671 E M 55
Practice Address - Street 2:
Practice Address - City:TAWAS CITY
Practice Address - State:MI
Practice Address - Zip Code:48763
Practice Address - Country:US
Practice Address - Phone:989-984-0560
Practice Address - Fax:989-984-0562
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-06
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI9807122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty