Provider Demographics
NPI:1669119152
Name:WIERENGA, MARK JOHN (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:JOHN
Last Name:WIERENGA
Suffix:
Gender:M
Credentials:DDS, MS
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4421 PENNY LN SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49418-9383
Mailing Address - Country:US
Mailing Address - Phone:616-862-8202
Mailing Address - Fax:
Practice Address - Street 1:3131 44TH ST SW
Practice Address - Street 2:
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-2684
Practice Address - Country:US
Practice Address - Phone:616-301-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-16
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010208721223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics