Provider Demographics
NPI:1770763583
Name:WICKSTRA, BENJAMIN H (DDS)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:H
Last Name:WICKSTRA
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 256
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:MI
Mailing Address - Zip Code:49419-0256
Mailing Address - Country:US
Mailing Address - Phone:269-751-4601
Mailing Address - Fax:
Practice Address - Street 1:3494 LINCOLN RD
Practice Address - Street 2:HAMILTON MEDICAL CENTER
Practice Address - City:HAMILTON
Practice Address - State:MI
Practice Address - Zip Code:49419
Practice Address - Country:US
Practice Address - Phone:269-751-4601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-08
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010195841223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program