Provider Demographics
NPI:1992091862
Name:WIETHOLDER, JOHN LOUIS (DMD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:LOUIS
Last Name:WIETHOLDER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4004 PEACH CT STE A
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-3800
Mailing Address - Country:US
Mailing Address - Phone:573-449-1918
Mailing Address - Fax:
Practice Address - Street 1:2441 21ST ST
Practice Address - Street 2:U S ARMY DENTAL ACTIVITY
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223-5582
Practice Address - Country:US
Practice Address - Phone:270-798-8614
Practice Address - Fax:270-798-8633
Is Sole Proprietor?:No
Enumeration Date:2011-06-20
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019028637122300000X
TNDS0000009522122300000X
MO2016009847122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist