Healthcare Provider Details

I. General information

NPI: 1023153400
Provider Name (Legal Business Name): ROBERT GUSTAV WIESE D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3046 LAVON DR 127
GARLAND TX
75040-8794
US

IV. Provider business mailing address

3046 LAVON DR 127
GARLAND TX
75040-8794
US

V. Phone/Fax

Practice location:
  • Phone: 972-414-7195
  • Fax: 972-496-1880
Mailing address:
  • Phone: 972-414-7195
  • Fax: 972-496-1880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number13823
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: