Provider Demographics
NPI:1609897560
Name:WIESE FAMILY DENTAL
Entity type:Organization
Organization Name:WIESE FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:M
Authorized Official - Last Name:WIESE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:319-351-9723
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental