Provider Demographics
NPI:1104814029
Name:WIESE, NICHOLAS (DDS)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:
Last Name:WIESE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 LINCOLN AVE NW
Mailing Address - Street 2:
Mailing Address - City:FARIBAULT
Mailing Address - State:MN
Mailing Address - Zip Code:55021-4952
Mailing Address - Country:US
Mailing Address - Phone:507-332-7608
Mailing Address - Fax:
Practice Address - Street 1:417 LINCOLN AVE NW
Practice Address - Street 2:
Practice Address - City:FARIBAULT
Practice Address - State:MN
Practice Address - Zip Code:55021-4952
Practice Address - Country:US
Practice Address - Phone:507-332-7608
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND11401122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist