Basic Information
| Provider Information | |||||||||
| NPI: | 1992091862 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WIETHOLDER | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | LOUIS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4004 PEACH CT STE A | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652033800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5734491918 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2441 21ST ST | ||||||||
| Address2: | U S ARMY DENTAL ACTIVITY | ||||||||
| City: | FORT CAMPBELL | ||||||||
| State: | KY | ||||||||
| PostalCode: | 422235582 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707988614 | ||||||||
| FaxNumber: | 2707988633 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2011 | ||||||||
| LastUpdateDate: | 05/25/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 019028637 | IL | N | Dental Providers | Dentist | 122300000X | DS0000009522 | TN | N | Dental Providers | Dentist | 122300000X | 2016009847 | MO | Y | Dental Providers | Dentist |
No ID Information.