Provider Demographics
NPI:1528102027
Name:WIEDEMAN, RICHARD WILLIAM (DDS)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:WILLIAM
Last Name:WIEDEMAN
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 1:15 JANE JACOBS RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BLACK MOUNTAIN
Mailing Address - State:NC
Mailing Address - Zip Code:28711-6306
Mailing Address - Country:US
Mailing Address - Phone:828-210-7051
Mailing Address - Fax:828-210-7052
Practice Address - Street 1:15 JANE JACOBS RD STE 201
Practice Address - Street 2:
Practice Address - City:BLACK MOUNTAIN
Practice Address - State:NC
Practice Address - Zip Code:28711-6308
Practice Address - Country:US
Practice Address - Phone:828-210-7051
Practice Address - Fax:828-210-7052
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20150183921223G0001X
NC70851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89012MJMedicaid