Provider Demographics
NPI:1710211388
Name:WIESEL, PETER E (DMD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:E
Last Name:WIESEL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 NEW ROAD
Mailing Address - Street 2:SUITE #401
Mailing Address - City:LINWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08221
Mailing Address - Country:US
Mailing Address - Phone:609-927-5300
Mailing Address - Fax:609-927-6731
Practice Address - Street 1:222 NEW ROAD
Practice Address - Street 2:SUITE #401
Practice Address - City:LINWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08221
Practice Address - Country:US
Practice Address - Phone:609-927-5300
Practice Address - Fax:609-927-6731
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-29
Last Update Date:2009-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DD101628200122300000X
NJ35541223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223P0700XDental ProvidersDentistProsthodontics