Provider Demographics
NPI:1063861474
Name:JOHN WIETHOLDER DMD PC
Entity Type:Organization
Organization Name:JOHN WIETHOLDER DMD PC
Other - Org Name:ALL AMERICAN DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:WIETHOLDER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:573-449-1918
Mailing Address - Street 1:601 W NIFONG BLVD
Mailing Address - Street 2:STE 3A
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-6804
Mailing Address - Country:US
Mailing Address - Phone:573-449-1918
Mailing Address - Fax:573-817-3161
Practice Address - Street 1:601 W NIFONG BLVD
Practice Address - Street 2:STE 3A
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-6804
Practice Address - Country:US
Practice Address - Phone:573-449-1918
Practice Address - Fax:573-817-3161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-07
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016009847122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO7592100001Medicare NSC