Healthcare Provider Details

I. General information

NPI: 1861133597
Provider Name (Legal Business Name): ALEX DAVID WEDIGE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 07/19/2022
Certification Date: 07/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

464 WATER ST
PRAIRIE DU SAC WI
53578-1127
US

IV. Provider business mailing address

612 N WASHINGTON ST
SPRING GREEN WI
53588-9114
US

V. Phone/Fax

Practice location:
  • Phone: 608-643-3855
  • Fax:
Mailing address:
  • Phone: 608-588-4303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number6001029-15
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: