Provider Demographics
NPI:1790005320
Name:WIESEN, ROBERT MICHAEL JR (DDS)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:MICHAEL
Last Name:WIESEN
Suffix:JR
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 1:8235 HOLLY RD STE 2
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-2441
Mailing Address - Country:US
Mailing Address - Phone:810-584-7275
Mailing Address - Fax:
Practice Address - Street 1:8235 HOLLY RD STE 2
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-2441
Practice Address - Country:US
Practice Address - Phone:810-584-7275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-05
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901020189122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist