Provider Demographics
NPI:1063755783
Name:WIETECHA, TOMASZ ADAM (LD, MD)
Entity type:Individual
Prefix:DR
First Name:TOMASZ
Middle Name:ADAM
Last Name:WIETECHA
Suffix:
Gender:M
Credentials:LD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3965 BETHEL RD SE
Mailing Address - Street 2:STE 2C
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366-1976
Mailing Address - Country:US
Mailing Address - Phone:360-876-0508
Mailing Address - Fax:
Practice Address - Street 1:3965 BETHEL RD SE
Practice Address - Street 2:STE 2C
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-1976
Practice Address - Country:US
Practice Address - Phone:360-876-0508
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-01
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADN60186659122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist