=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003229659
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | W&W DENTISTRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/10/2014
-----------------------------------------------------
Last Update Date | 06/10/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2000 43RD ST SE SUITE C
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49508-8700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-455-4108
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2000 43RD ST SE SUITE C
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49508-8700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-455-4108
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | DR. BRIAN A WIEDEMER
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 616-455-4108
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 2901019908
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 2901019234
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------