Provider Demographics
NPI:1689796310
Name:WIEGAND, PHILIP JOSEPH (DDS)
Entity Type:Individual
Prefix:MR
First Name:PHILIP
Middle Name:JOSEPH
Last Name:WIEGAND
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 1:1714 WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:PA
Mailing Address - Zip Code:18042
Mailing Address - Country:US
Mailing Address - Phone:610-258-4379
Mailing Address - Fax:610-258-3145
Practice Address - Street 1:1714 WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:PA
Practice Address - Zip Code:18042
Practice Address - Country:US
Practice Address - Phone:610-258-4379
Practice Address - Fax:610-258-3145
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS018298L1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0531603OtherMEDICAL ASSISTANCE