MEDICARE: DR. DIANNE C. WEIDNER D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	11437	MI

General Provider Information

NPI Number	:	1124321195
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DIANNE C. WEIDNER D.D.S.

Provider Business Mailing Address
First Line	:	3433 EAST MIDLAND ROAD
Second Line	:
City	:	BAY CITY
State	:	MI
Zip	:	48706-2895
Country	:	US
Telephone Number	:	989-686-6110
Fax Number	:	989-686-6170

Provider Business Practice Location Address
First Line	:	3433 E MIDLAND RD
Second Line	:
City	:	BAY CITY
State	:	MI
Zip	:	48706-2825
Country	:	US
Telephone Number	:	989-686-6110
Fax Number	:	989-686-6170

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/14/2010
Last Update Date	:	12/14/2010

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