MEDICARE: DR. TRYSTAN RICHARD WIEDOW DDS

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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	1002773-15	WI
2	390200000X	Student in an Organized Health Care Education/Training Program	1002773	WI
3	390200000X	Student in an Organized Health Care Education/Training Program	RES-30614	IA

General Provider Information

NPI Number	:	1427639038
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TRYSTAN RICHARD WIEDOW DDS

Provider Business Mailing Address
First Line	:	2353 S RIDGE RD STE 1
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54304-5069
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2353 S RIDGE RD
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54304-5857
Country	:	US
Telephone Number	:	920-499-0471
Fax Number	:

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

Provider Enumeration Date	:	04/15/2021
Last Update Date	:	06/20/2026

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