Provider Demographics
NPI:1578506721
Name:WIESJAHN, HOWARD (DDS)
Entity Type:Individual
Prefix:
First Name:HOWARD
Middle Name:
Last Name:WIESJAHN
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:PO BOX 853
Mailing Address - Street 2:
Mailing Address - City:NEW CARLISLE
Mailing Address - State:IN
Mailing Address - Zip Code:46552-0853
Mailing Address - Country:US
Mailing Address - Phone:574-654-8811
Mailing Address - Fax:574-654-8809
Practice Address - Street 1:132 E MICHIGAN STREET
Practice Address - Street 2:
Practice Address - City:NEW CARLISLE
Practice Address - State:IN
Practice Address - Zip Code:46552
Practice Address - Country:US
Practice Address - Phone:574-654-8811
Practice Address - Fax:574-654-8809
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120079121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice