Basic Information
| Provider Information | |||||||||
| NPI: | 1063861474 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JOHN WIETHOLDER DMD PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ALL AMERICAN DENTAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 601 W NIFONG BLVD | ||||||||
| Address2: | STE 3A | ||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652036804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5734491918 | ||||||||
| FaxNumber: | 5738173161 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 W NIFONG BLVD | ||||||||
| Address2: | STE 3A | ||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652036804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5734491918 | ||||||||
| FaxNumber: | 5738173161 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2016 | ||||||||
| LastUpdateDate: | 05/02/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WIETHOLDER | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | LOUIS | ||||||||
| AuthorizedOfficialTitleorPosition: | DENTIST/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5734491918 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DMD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 2016009847 | MO | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist |
No ID Information.