Provider Demographics
NPI:1942906631
Name:DITTMAN, WESLEY WILLIAM
Entity Type:Individual
Prefix:
First Name:WESLEY
Middle Name:WILLIAM
Last Name:DITTMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 GRANDVIEW CT APT 400
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52246-3208
Mailing Address - Country:US
Mailing Address - Phone:715-581-4600
Mailing Address - Fax:
Practice Address - Street 1:735 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:MARSHFIELD
Practice Address - State:WI
Practice Address - Zip Code:54449-4106
Practice Address - Country:US
Practice Address - Phone:715-384-3515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-03
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6001217-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice