Provider Demographics
NPI:1215374335
Name:WIESE, CAROL (DDS)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:WIESE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 SHERIDAN LAKE RD
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-2407
Mailing Address - Country:US
Mailing Address - Phone:605-721-6634
Mailing Address - Fax:605-341-5757
Practice Address - Street 1:700 SHERIDAN LAKE RD.
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702
Practice Address - Country:US
Practice Address - Phone:605-721-6634
Practice Address - Fax:605-341-5757
Is Sole Proprietor?:No
Enumeration Date:2013-05-30
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010209641223G0001X
SDD13611223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral Practice