Provider Demographics
NPI:1568472041
Name:WIEGERS, JAMES J
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:J
Last Name:WIEGERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 FIVE IRON CT
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62220-3234
Mailing Address - Country:US
Mailing Address - Phone:618-233-4606
Mailing Address - Fax:618-233-7806
Practice Address - Street 1:4 S CHURCH ST
Practice Address - Street 2:SUITE 302
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-2236
Practice Address - Country:US
Practice Address - Phone:618-233-6311
Practice Address - Fax:618-233-7806
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19A128201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice