Provider Demographics
NPI:1811037385
Name:WIEBE, JOHN D (DDS)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:D
Last Name:WIEBE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:4815 PAULSEN ST
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-4418
Mailing Address - Country:US
Mailing Address - Phone:912-352-2324
Mailing Address - Fax:912-354-0935
Practice Address - Street 1:4815 PAULSEN ST
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-4418
Practice Address - Country:US
Practice Address - Phone:912-352-2324
Practice Address - Fax:912-354-0935
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2009-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0096691223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA02643168Medicaid
GA9183964OtherDORAL DENTAL MEDICAID
SCZZ9669OtherSOUTH CAROLINA
GAT92027Medicare UPIN