Active NPI
Dominik Wietrzynski, D.D.S.
- Dentist
- Warren, MI
National Provider Identifier
1750693149
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- License
- 2901020331
- Practice address
- 11552 E 12 Mile Rd
Warren, MI 48093-2644 - Phone
- (586) 573-2533
- NPI assigned
- Jul 14, 2010
- 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 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 019.028405 | IL | |
| Dentist | 122300000X | 2901020331 | MI | Primary |
Addresses
Primary practice location
11552 E 12 Mile Rd
Warren, MI 48093-2644
Mailing address
11552 E 12 Mile Rd
Warren, MI 48093-2644
Phone (586) 573-2533
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in MI
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: No
- Hospice: Yes
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20160106000361 | MI | Order and Referring Only - Oral Surgery | 4385946532 |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 019.028405 | IL | MD | Dentist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1279065600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1315440000000",
"number": "1750693149",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "11552 E 12 MILE RD",
"city": "WARREN",
"state": "MI",
"postal_code": "480932644",
"telephone_number": "586-573-2533"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "11552 E 12 MILE RD",
"city": "WARREN",
"state": "MI",
"postal_code": "480932644",
"telephone_number": "586-573-2533"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WIETRZYNSKI",
"first_name": "DOMINIK",
"credential": "D.D.S.",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2010-07-14",
"last_updated": "2011-09-08",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "IL",
"license": "019.028405",
"primary": false
},
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "MI",
"license": "2901020331",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Warren, MI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 8, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.