Provider Demographics
NPI:1750528774
Name:WEIDIG, PAULA SMIHAL (RDH, MED)
Entity type:Individual
Prefix:
First Name:PAULA
Middle Name:SMIHAL
Last Name:WEIDIG
Suffix:
Gender:F
Credentials:RDH, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4291 GRATIOT AVE
Mailing Address - Street 2:
Mailing Address - City:FORT GRATIOT
Mailing Address - State:MI
Mailing Address - Zip Code:48059-3900
Mailing Address - Country:US
Mailing Address - Phone:810-385-7545
Mailing Address - Fax:
Practice Address - Street 1:4291 GRATIOT AVE
Practice Address - Street 2:
Practice Address - City:FORT GRATIOT
Practice Address - State:MI
Practice Address - Zip Code:48059-3900
Practice Address - Country:US
Practice Address - Phone:810-385-7545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-13
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902013552124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist