Provider Demographics
NPI:1043265200
Name:WIESE, CHAD MICHAEL (DDS)
Entity type:Individual
Prefix:DR
First Name:CHAD
Middle Name:MICHAEL
Last Name:WIESE
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 1:1004 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:IA
Mailing Address - Zip Code:52353-2149
Mailing Address - Country:US
Mailing Address - Phone:319-653-2201
Mailing Address - Fax:319-653-5548
Practice Address - Street 1:1004 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:IA
Practice Address - Zip Code:52353-2149
Practice Address - Country:US
Practice Address - Phone:319-653-2201
Practice Address - Fax:319-653-5548
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA082091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice