Individual
DR. TRYSTAN RICHARD WIEDOW
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DDS
Contact information
Practice address
2353 S RIDGE RD, GREEN BAY, WI 54304-5857
(920) 499-0471
Mailing address
2353 S RIDGE RD STE 1, GREEN BAY, WI 54304-5069
Taxonomy
Speciality
Code
Description
License number
State
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
Primary
1002773-15
WI
390200000X
Student in an Organized Health Care Education/Training Program
1002773
WI
390200000X
Student in an Organized Health Care Education/Training Program
RES-30614
IA
Other
Enumeration date
04/15/2021
Last updated
06/20/2026
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