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General NPI Number Information
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NPI Number | 1063861474
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Entity Type | Organization
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Legal Business Name | JOHN WIETHOLDER DMD PC
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Dates
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Enumeration Date | 06/07/2016
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Last Update Date | 05/02/2017
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Provider Practice Location Address
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Address Line | 601 W NIFONG BLVD STE 3A
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City | COLUMBIA
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State | MO
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Zip | 65203-6804
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Country | US
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Telephone | 573-449-1918
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Fax | 573-817-3161
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Provider Business Mailing Address
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Address Line | 601 W NIFONG BLVD STE 3A
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City | COLUMBIA
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State | MO
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Zip | 65203-6804
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Country | US
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Telephone | 573-449-1918
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Fax | 573-817-3161
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Authorized Official
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Title or Position | DENTIST/OWNER
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Name | DR. JOHN LOUIS WIETHOLDER
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Credential | DMD
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Telephone | 573-449-1918
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 2016009847
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License Number State | MO
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