Provider Demographics
NPI:1912010216
Name:WIENKE, JERALD D (DDS)
Entity Type:Individual
Prefix:MR
First Name:JERALD
Middle Name:D
Last Name:WIENKE
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:PO BOX 990
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86402-0990
Mailing Address - Country:US
Mailing Address - Phone:928-753-6220
Mailing Address - Fax:928-753-6343
Practice Address - Street 1:411 GRANDVIEW AVE
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-5745
Practice Address - Country:US
Practice Address - Phone:928-753-6220
Practice Address - Fax:928-753-6343
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ13711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice