Individual
DR. JOHN LOUIS WIETHOLDER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DMD
Contact information
Practice address
2441 21ST ST, U S ARMY DENTAL ACTIVITY, FORT CAMPBELL, KY 42223-5582
(270) 798-8614
(270) 798-8633
Mailing address
4004 PEACH CT STE A, COLUMBIA, MO 65203-3800
(573) 449-1918
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
019028637
IL
122300000X
Dentist
Primary
2016009847
MO
122300000X
Dentist
DS0000009522
TN
Other
Enumeration date
06/20/2011
Last updated
05/25/2021
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