Provider Demographics
NPI:1255821443
Name:HUMBLE, MICHELLE CAROLYN WIECZYNSKI (DDS, BS)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:CAROLYN WIECZYNSKI
Last Name:HUMBLE
Suffix:
Gender:F
Credentials:DDS, BS
Other - Prefix:MS
Other - First Name:MICHELLE
Other - Middle Name:CAROLYN
Other - Last Name:WIECZYNSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BS
Mailing Address - Street 1:213 S JEFFERSON ST STE 1006
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24011-1713
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4348 ELECTRIC RD
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-0720
Practice Address - Country:US
Practice Address - Phone:540-769-0976
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-14
Last Update Date:2024-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401416151122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice