Provider Demographics
NPI:1093140360
Name:WIETECHA, BENJAMIN THOMAS (DMD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:THOMAS
Last Name:WIETECHA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 MEDICAL PARK
Mailing Address - Street 2:DENTAL CENTER
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203
Mailing Address - Country:US
Mailing Address - Phone:803-434-6567
Mailing Address - Fax:803-434-6299
Practice Address - Street 1:10 MEDICAL PARK
Practice Address - Street 2:DENTAL CENTER
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203
Practice Address - Country:US
Practice Address - Phone:803-434-6567
Practice Address - Fax:803-434-6299
Is Sole Proprietor?:No
Enumeration Date:2013-09-05
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8293122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist