Provider Demographics
NPI:1689932055
Name:WIETING, DAVID S (DDS)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:S
Last Name:WIETING
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 1:122 WEST 6TH STREET
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:NE
Mailing Address - Zip Code:68467
Mailing Address - Country:US
Mailing Address - Phone:402-362-3379
Mailing Address - Fax:402-362-3370
Practice Address - Street 1:122 WEST 6TH STREET
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:NE
Practice Address - Zip Code:68467
Practice Address - Country:US
Practice Address - Phone:402-362-3379
Practice Address - Fax:402-362-3370
Is Sole Proprietor?:No
Enumeration Date:2012-04-24
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE4785122300000X
CO9889122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47060373000Medicaid