Provider Demographics
NPI:1851685226
Name:BENJAMIN H. WICKSTRA DDS, PLLC
Entity Type:Organization
Organization Name:BENJAMIN H. WICKSTRA DDS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:H
Authorized Official - Last Name:WICKSTRA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:616-218-5795
Mailing Address - Street 1:567 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-4848
Mailing Address - Country:US
Mailing Address - Phone:616-218-5795
Mailing Address - Fax:
Practice Address - Street 1:567 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-4848
Practice Address - Country:US
Practice Address - Phone:616-218-5795
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BH WICKSTRA DDS PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-06-02
Last Update Date:2011-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010195841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty