Provider Demographics
NPI:1437721164
Name:WIESE, KARL G (DDS)
Entity Type:Individual
Prefix:DR
First Name:KARL
Middle Name:G
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 1:9436 NARCOOSSEE RD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32827-5705
Mailing Address - Country:US
Mailing Address - Phone:321-300-2235
Mailing Address - Fax:321-290-1545
Practice Address - Street 1:9436 NARCOOSSEE RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32827-5705
Practice Address - Country:US
Practice Address - Phone:321-300-2235
Practice Address - Fax:321-290-1545
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-13
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN26231122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist