Provider Demographics
NPI:1699900399
Name:WIEDENMAN, CHARLOTTE COLLINS (DMD)
Entity type:Individual
Prefix:DR
First Name:CHARLOTTE
Middle Name:COLLINS
Last Name:WIEDENMAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:CHARLOTTE
Other - Middle Name:L
Other - Last Name:COLLINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:129 FAUBURG ST SW
Mailing Address - Street 2:
Mailing Address - City:AIKEN
Mailing Address - State:SC
Mailing Address - Zip Code:29801-3805
Mailing Address - Country:US
Mailing Address - Phone:803-649-0430
Mailing Address - Fax:803-522-1878
Practice Address - Street 1:129 FAUBURG ST SW
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29801-3805
Practice Address - Country:US
Practice Address - Phone:803-649-0430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-25
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3844122300000X, 1223G0001X
GA012182122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC17697Medicaid
SCZX3844Medicaid