Provider Demographics
NPI:1518134006
Name:WIEDERRICH, ROBIN RICHARD (DPD)
Entity Type:Individual
Prefix:
First Name:ROBIN
Middle Name:RICHARD
Last Name:WIEDERRICH
Suffix:
Gender:M
Credentials:DPD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9323 MCKENNA FALLS RD W
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98312-9730
Mailing Address - Country:US
Mailing Address - Phone:360-277-0964
Mailing Address - Fax:360-277-0967
Practice Address - Street 1:9323 MCKENNA FALLS RD W
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98312-9730
Practice Address - Country:US
Practice Address - Phone:360-277-0964
Practice Address - Fax:360-277-0967
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-13
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADN00000371122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5046198Medicaid