Provider Demographics
NPI:1346239043
Name:WIEDEMANN, WERNER ERNST (DDS)
Entity type:Individual
Prefix:
First Name:WERNER
Middle Name:ERNST
Last Name:WIEDEMANN
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 1:33 N BANK ST
Mailing Address - Street 2:
Mailing Address - City:LURAY
Mailing Address - State:VA
Mailing Address - Zip Code:22835-1115
Mailing Address - Country:US
Mailing Address - Phone:540-743-3434
Mailing Address - Fax:
Practice Address - Street 1:33 N BANK ST
Practice Address - Street 2:
Practice Address - City:LURAY
Practice Address - State:VA
Practice Address - Zip Code:22835-1115
Practice Address - Country:US
Practice Address - Phone:540-743-3434
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010060091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA7819200Medicaid