Provider Demographics
NPI:1518410281
Name:NATHANIEL WIEDER, DMD, P.C.
Entity Type:Organization
Organization Name:NATHANIEL WIEDER, DMD, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NATHANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WIEDER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:516-316-4480
Mailing Address - Street 1:390 BERRY ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11249-6084
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:390 BERRY ST
Practice Address - Street 2:SUITE B
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11249-6084
Practice Address - Country:US
Practice Address - Phone:718-218-7210
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-29
Last Update Date:2016-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY058348-11223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty