Provider Demographics
NPI:1245353168
Name:WINE, MICHAEL J (DDS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:WINE
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 1:6797 SHIRE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:VICTOR
Mailing Address - State:ID
Mailing Address - Zip Code:83455-5036
Mailing Address - Country:US
Mailing Address - Phone:614-648-6657
Mailing Address - Fax:
Practice Address - Street 1:610 W BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8213
Practice Address - Country:US
Practice Address - Phone:307-732-2273
Practice Address - Fax:307-732-1660
Is Sole Proprietor?:No
Enumeration Date:2007-04-07
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1325122300000X
IDD 4424122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist