Provider Demographics
NPI:1912165556
Name:WICKSALL, MICHEL MARIE (DDS)
Entity Type:Individual
Prefix:MISS
First Name:MICHEL
Middle Name:MARIE
Last Name:WICKSALL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4500 CASCADE RD SE
Mailing Address - Street 2:200
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546
Mailing Address - Country:US
Mailing Address - Phone:616-975-9700
Mailing Address - Fax:616-975-9750
Practice Address - Street 1:4500 CASCADE RD SE
Practice Address - Street 2:200
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546
Practice Address - Country:US
Practice Address - Phone:616-975-9700
Practice Address - Fax:616-975-9750
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-30
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI16961122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist