Provider Demographics
NPI:1720442734
Name:WIEDEMANN, THOMAS GEORG (MD, DDS)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:GEORG
Last Name:WIEDEMANN
Suffix:
Gender:M
Credentials:MD, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:345 E 24 TH STREET
Mailing Address - Street 2:NYU-COLLEGE OF DENTISTRY
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10010-4020
Mailing Address - Country:US
Mailing Address - Phone:212-998-9667
Mailing Address - Fax:212-995-4920
Practice Address - Street 1:345 E 24TH ST
Practice Address - Street 2:NYU-COLLEGE OF DENTISTRY
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-4020
Practice Address - Country:US
Practice Address - Phone:212-998-9667
Practice Address - Fax:212-995-4920
Is Sole Proprietor?:No
Enumeration Date:2016-04-06
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0000691223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery