Healthcare Provider Details

I. General information

NPI: 1609897560
Provider Name (Legal Business Name): WIESE FAMILY DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2006
Last Update Date: 10/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1004 E WASHINGTON ST
WASHINGTON IA
52353-2149
US

IV. Provider business mailing address

1004 E WASHINGTON ST
WASHINGTON IA
52353-2149
US

V. Phone/Fax

Practice location:
  • Phone: 319-653-2201
  • Fax: 319-653-5548
Mailing address:
  • Phone: 319-653-2201
  • Fax: 319-653-5548

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. CHAD M WIESE
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 319-351-9723