Provider Demographics
NPI:1790876167
Name:WIELE, GARY BRIAN (DDS)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:BRIAN
Last Name:WIELE
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 1:2821 N BALLAS RD
Mailing Address - Street 2:STE 260
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131
Mailing Address - Country:US
Mailing Address - Phone:314-475-5333
Mailing Address - Fax:314-475-5334
Practice Address - Street 1:2821 N BALLAS RD
Practice Address - Street 2:STE 260
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131
Practice Address - Country:US
Practice Address - Phone:314-475-5333
Practice Address - Fax:314-475-5334
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO139371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice