Provider Demographics
NPI:1871544320
Name:WICKSTRA, DONALD JAY (DDS)
Entity type:Individual
Prefix:DR
First Name:DONALD
Middle Name:JAY
Last Name:WICKSTRA
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 1:4023 134TH AVE
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:MI
Mailing Address - Zip Code:49419-9564
Mailing Address - Country:US
Mailing Address - Phone:269-751-4601
Mailing Address - Fax:269-751-4522
Practice Address - Street 1:3494 LINCOLN RD
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:MI
Practice Address - Zip Code:49419-9512
Practice Address - Country:US
Practice Address - Phone:269-751-4601
Practice Address - Fax:269-751-4522
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI122701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0004050379Medicaid