Provider Demographics
NPI:1497115620
Name:WIELAND, MICHAEL KARL (DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:KARL
Last Name:WIELAND
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 1:30 HAMPTON PL
Mailing Address - Street 2:
Mailing Address - City:SICKLERVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08081-2504
Mailing Address - Country:US
Mailing Address - Phone:609-230-6328
Mailing Address - Fax:
Practice Address - Street 1:30 HAMPTON PL
Practice Address - Street 2:
Practice Address - City:SICKLERVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08081-2504
Practice Address - Country:US
Practice Address - Phone:609-230-6328
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-01
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDIO18233122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist