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General NPI Number Information
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NPI Number | 1245390798
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Entity Type | Organization
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Legal Business Name | THOMAS R. WIEDEMANN, DDS,PC
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Dates
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Enumeration Date | 12/12/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 3707 WATSON RD
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City | SAINT LOUIS
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State | MO
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Zip | 63109-1236
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Country | US
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Telephone | 314-645-6400
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Fax |
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Provider Business Mailing Address
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Address Line | 3707 WATSON RD
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City | SAINT LOUIS
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State | MO
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Zip | 63109-1236
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Country | US
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Telephone | 314-645-6400
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. THOMAS R WIEDEMANN
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Credential | DDS
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Telephone | 314-645-6400
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 13165
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License Number State | MO
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