Provider Demographics
NPI:1740574458
Name:WIESEMANN ORTHODONTICS INC. PC
Entity Type:Organization
Organization Name:WIESEMANN ORTHODONTICS INC. PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTISTS/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:B
Authorized Official - Last Name:WIESEMANN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD,MS
Authorized Official - Phone:615-325-4677
Mailing Address - Street 1:323 WEST DR
Mailing Address - Street 2:
Mailing Address - City:WHITE HOUSE
Mailing Address - State:TN
Mailing Address - Zip Code:37188-9294
Mailing Address - Country:US
Mailing Address - Phone:615-325-4677
Mailing Address - Fax:
Practice Address - Street 1:894 FRED LIVELY RD
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-7424
Practice Address - Country:US
Practice Address - Phone:616-325-4677
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-31
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN85031223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty