Provider Demographics
NPI:1003229659
Name:W&W DENTISTRY
Entity Type:Organization
Organization Name:W&W DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:WIEDEMER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:616-455-4108
Mailing Address - Street 1:2000 43RD ST SE
Mailing Address - Street 2:SUITE C
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49508-8700
Mailing Address - Country:US
Mailing Address - Phone:616-455-4108
Mailing Address - Fax:
Practice Address - Street 1:2000 43RD ST SE
Practice Address - Street 2:SUITE C
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49508-8700
Practice Address - Country:US
Practice Address - Phone:616-455-4108
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-10
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901019908122300000X
MI2901019234122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty