Provider Demographics
NPI:1790845808
Name:WIEDERHOLD, DARRIN MICHAEL (DMD MS)
Entity Type:Individual
Prefix:DR
First Name:DARRIN
Middle Name:MICHAEL
Last Name:WIEDERHOLD
Suffix:
Gender:M
Credentials:DMD MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 12TH AVE S STE 901
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98144-2712
Mailing Address - Country:US
Mailing Address - Phone:206-548-3058
Mailing Address - Fax:206-262-0859
Practice Address - Street 1:525 LILLY RD NE STE 110
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5101
Practice Address - Country:US
Practice Address - Phone:570-205-3948
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0369721223G0001X
CA555311223G0001X
WADE613068501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WADE61306850OtherDENTAL LICENSE