Provider Demographics
NPI:1083823678
Name:WIESE, JAMES BENNETT (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:BENNETT
Last Name:WIESE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 W CENTRAL RD
Mailing Address - Street 2:SUITE 406
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60005-2402
Mailing Address - Country:US
Mailing Address - Phone:847-398-8300
Mailing Address - Fax:847-398-8325
Practice Address - Street 1:1100 W CENTRAL RD
Practice Address - Street 2:SUITE 406
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60005-2402
Practice Address - Country:US
Practice Address - Phone:847-398-8300
Practice Address - Fax:847-398-8325
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice