Basic Information
| Provider Information | |||||||||
| NPI: | 1669691739 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WIELAND | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 155 LAWN AVE | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142071816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168752904 | ||||||||
| FaxNumber: | 7165150711 | ||||||||
| Practice Location | |||||||||
| Address1: | 155 LAWN AVE | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142071816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168752904 | ||||||||
| FaxNumber: | 7165150711 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2007 | ||||||||
| LastUpdateDate: | 11/13/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 043764 | NY | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 000728971001 | 01 | NY | BC BS | OTHER | 16294447-0002 | 01 | NY | GHI | OTHER | 161294447 | 01 | NY | HEALTHPLEX | OTHER | 4014142 | 01 | NY | INDEPENDENT HEALTH | OTHER | 161294447 | 01 | NY | NOVA | OTHER |