Provider Demographics
NPI:1114197886
Name:WIESE, THOMAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:
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 1:10712 S EWING AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617-6626
Mailing Address - Country:US
Mailing Address - Phone:773-734-6679
Mailing Address - Fax:
Practice Address - Street 1:10712 S EWING AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-6626
Practice Address - Country:US
Practice Address - Phone:773-734-6679
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-09
Last Update Date:2008-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist