Provider Demographics
NPI:1144776543
Name:WIESE, LAUREN
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:WIESE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 ACORN HILL HOLW
Mailing Address - Street 2:
Mailing Address - City:VOORHEES
Mailing Address - State:NJ
Mailing Address - Zip Code:08043-1524
Mailing Address - Country:US
Mailing Address - Phone:609-841-8121
Mailing Address - Fax:
Practice Address - Street 1:957 ROUTE 33
Practice Address - Street 2:
Practice Address - City:HAMILTON SQUARE
Practice Address - State:NJ
Practice Address - Zip Code:08690
Practice Address - Country:US
Practice Address - Phone:609-587-5858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-26
Last Update Date:2019-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD16148122300000X
CT12451122300000X
390200000X
NJ0265321223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program