Provider Demographics
NPI:1861060568
Name:WIRZ, MACALL NABORS (DDS)
Entity type:Individual
Prefix:
First Name:MACALL
Middle Name:NABORS
Last Name:WIRZ
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 CHAPEL ST APT 531
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510-3161
Mailing Address - Country:US
Mailing Address - Phone:423-385-4575
Mailing Address - Fax:
Practice Address - Street 1:1761 W BROAD ST
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:CT
Practice Address - Zip Code:06615-5752
Practice Address - Country:US
Practice Address - Phone:203-375-3763
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-17
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT13496122300000X, 1223G0001X
TN116061223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist