Provider Demographics
NPI:1437288354
Name:WEIDENFELLER, JOHN ARLEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ARLEN
Last Name:WEIDENFELLER
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 1:4298 CASCADE RD SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-8301
Mailing Address - Country:US
Mailing Address - Phone:616-942-7050
Mailing Address - Fax:616-942-7146
Practice Address - Street 1:4298 CASCADE RD SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8301
Practice Address - Country:US
Practice Address - Phone:616-942-7050
Practice Address - Fax:616-942-7146
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0148261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice