Provider Demographics
NPI:1538238217
Name:WENY, BRUCE M (DDS)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:M
Last Name:WENY
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 1:255 WASHINGTON ST SE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4350
Mailing Address - Country:US
Mailing Address - Phone:616-451-2336
Mailing Address - Fax:616-222-1345
Practice Address - Street 1:255 WASHINGTON ST SE
Practice Address - Street 2:SUITE 4
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4350
Practice Address - Country:US
Practice Address - Phone:616-451-2336
Practice Address - Fax:616-222-1345
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901010503122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4037635Medicaid