Provider Demographics
NPI:1831107705
Name:WISNIEWSKI, MARK A (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:WISNIEWSKI
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 1:78 COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01301
Mailing Address - Country:US
Mailing Address - Phone:413-774-5591
Mailing Address - Fax:413-772-6768
Practice Address - Street 1:78 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:MA
Practice Address - Zip Code:01301
Practice Address - Country:US
Practice Address - Phone:413-774-5591
Practice Address - Fax:413-772-6768
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA166971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice