Healthcare Provider Details

I. General information

NPI: 1174726145
Provider Name (Legal Business Name): JONATHAN WALTER WEIDEMANN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5963 EAST SPRING STREET
LONG BEACH CA
90808
US

IV. Provider business mailing address

830 CHILDS WAY #703
LOS ANGELES CA
90815-0277
US

V. Phone/Fax

Practice location:
  • Phone: 562-421-8401
  • Fax: 562-421-4069
Mailing address:
  • Phone: 562-431-1183
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number45538
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: