Healthcare Provider Details

I. General information

NPI: 1538321070
Provider Name (Legal Business Name): YVETTE KJELLAND WIESENMAYER D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2008
Last Update Date: 06/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 N MAIN ST
UNION BRIDGE MD
21791-9101
US

IV. Provider business mailing address

105 N MAIN ST
UNION BRIDGE MD
21791-9101
US

V. Phone/Fax

Practice location:
  • Phone: 410-775-7878
  • Fax:
Mailing address:
  • Phone: 410-775-7878
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number14084
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: