Healthcare Provider Details

I. General information

NPI: 1427639038
Provider Name (Legal Business Name): TRYSTAN RICHARD WIEDOW DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2021
Last Update Date: 06/20/2026
Certification Date: 06/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2353 S RIDGE RD
GREEN BAY WI
54304-5857
US

IV. Provider business mailing address

2353 S RIDGE RD STE 1
GREEN BAY WI
54304-5069
US

V. Phone/Fax

Practice location:
  • Phone: 920-499-0471
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number1002773-15
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number1002773
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberRES-30614
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: