Provider Demographics
NPI:1154524817
Name:WIESNER, MICHAEL R (DDS)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:WIESNER
Suffix:
Gender:
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:385 BERT KOUNS LOOP STE 700
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-8163
Mailing Address - Country:US
Mailing Address - Phone:318-779-1254
Mailing Address - Fax:
Practice Address - Street 1:385 BERT KOUNS LOOP STE 700
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-8163
Practice Address - Country:US
Practice Address - Phone:318-688-9330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-08
Last Update Date:2025-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5831204E00000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery