Provider Demographics
NPI:1235286105
Name:WIESEMANN, RYAN (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:
Last Name:WIESEMANN
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:894 FRED LIVELY RD
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-7424
Mailing Address - Country:US
Mailing Address - Phone:615-325-4677
Mailing Address - Fax:
Practice Address - Street 1:323 WEST DR
Practice Address - Street 2:
Practice Address - City:WHITE HOUSE
Practice Address - State:TN
Practice Address - Zip Code:37188-9294
Practice Address - Country:US
Practice Address - Phone:615-325-4677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN85031223X0400X
KY81251223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics