Provider Demographics
NPI:1386273878
Name:WIESE, COLLEEN MARIE (DDS)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:MARIE
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 1:14690 NW 151ST BLVD # 20
Mailing Address - Street 2:
Mailing Address - City:ALACHUA
Mailing Address - State:FL
Mailing Address - Zip Code:32615-5328
Mailing Address - Country:US
Mailing Address - Phone:386-462-1771
Mailing Address - Fax:
Practice Address - Street 1:14690 NW 151ST BLVD # 20
Practice Address - Street 2:
Practice Address - City:ALACHUA
Practice Address - State:FL
Practice Address - Zip Code:32615-5328
Practice Address - Country:US
Practice Address - Phone:386-462-1771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-06
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL390200000X
FLDN25264122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program