Provider Demographics
NPI:1538321070
Name:WIESENMAYER, YVETTE KJELLAND (DDS)
Entity Type:Individual
Prefix:DR
First Name:YVETTE
Middle Name:KJELLAND
Last Name:WIESENMAYER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:UNION BRIDGE
Mailing Address - State:MD
Mailing Address - Zip Code:21791-9101
Mailing Address - Country:US
Mailing Address - Phone:410-775-7878
Mailing Address - Fax:
Practice Address - Street 1:105 N MAIN ST
Practice Address - Street 2:
Practice Address - City:UNION BRIDGE
Practice Address - State:MD
Practice Address - Zip Code:21791-9101
Practice Address - Country:US
Practice Address - Phone:410-775-7878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-26
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD14084122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist