Provider Demographics
NPI:1750101606
Name:MICHAEL R. WIESNER DDS LLC
Entity type:Organization
Organization Name:MICHAEL R. WIESNER DDS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE BILLING LEAD
Authorized Official - Prefix:
Authorized Official - First Name:INGER
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITTINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-606-7622
Mailing Address - Street 1:2557 VIKING DR
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-2103
Mailing Address - Country:US
Mailing Address - Phone:318-606-7622
Mailing Address - Fax:318-212-6539
Practice Address - Street 1:385 BERT KOUNS LOOP STE 700
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-8163
Practice Address - Country:US
Practice Address - Phone:318-688-9330
Practice Address - Fax:318-212-6539
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-15
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty