Provider Demographics
NPI:1790782399
Name:WIEDEMANN, THOMAS R (DDS)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:R
Last Name:WIEDEMANN
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 1:3707 WATSON RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63109-1236
Mailing Address - Country:US
Mailing Address - Phone:314-645-6400
Mailing Address - Fax:
Practice Address - Street 1:3707 WATSON RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63109-1236
Practice Address - Country:US
Practice Address - Phone:314-645-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO131651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO13165OtherSTATE LICENSE