Provider Demographics
NPI:1467453712
Name:WEDDLE, STEPHEN J (DDS)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:J
Last Name:WEDDLE
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 1:605 PETERSON DR
Mailing Address - Street 2:PO BOX 10
Mailing Address - City:PHILLIPS
Mailing Address - State:WI
Mailing Address - Zip Code:54555-1430
Mailing Address - Country:US
Mailing Address - Phone:715-339-3021
Mailing Address - Fax:
Practice Address - Street 1:605 PETERSON DR
Practice Address - Street 2:
Practice Address - City:PHILLIPS
Practice Address - State:WI
Practice Address - Zip Code:54555-1430
Practice Address - Country:US
Practice Address - Phone:715-339-3021
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-09
Last Update Date:2007-07-08
Deactivation Date:2006-04-05
Deactivation Code:
Reactivation Date:2006-04-10
Provider Licenses
StateLicense IDTaxonomies
WI50017011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice