Active NPI
Joel Gregory Wiersum Sr., DDS
- Dentist
- Kodiak, AK
National Provider Identifier
1467462341
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- License
- AA799
- Practice address
- 411 Rezanof Dr E
Suite 101
Kodiak, AK 99615 - Phone
- (907) 486-3475
- Fax
- (907) 486-3427
- NPI assigned
- Aug 9, 2006
- Last updated
- Jul 8, 2007
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | AA799 | AK | Primary |
Addresses
Primary practice location
411 Rezanof Dr E
Suite 101
Kodiak, AK 99615
Mailing address
411 Rezanof Dr E
Suite 101
Kodiak, AK 99615
Phone (907) 486-3475
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| DD0799 | Medicaid | AK |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| AA799 | AK | MD | Dentist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1155081600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1467462341",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "411 REZANOF DR E",
"address_2": "SUITE 101",
"city": "KODIAK",
"state": "AK",
"postal_code": "99615",
"telephone_number": "907-486-3475",
"fax_number": "907-486-3427"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "411 REZANOF DR E",
"address_2": "SUITE 101",
"city": "KODIAK",
"state": "AK",
"postal_code": "99615",
"telephone_number": "907-486-3475",
"fax_number": "907-486-3427"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WIERSUM",
"first_name": "JOEL",
"middle_name": "GREGORY",
"name_suffix": "Sr.",
"credential": "DDS",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-08-09",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "AK",
"license": "AA799",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "DD0799",
"state": "AK"
}
],
"endpoints": [],
"other_names": []
}Other providers in Kodiak, AK
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.