Basic Information
| Provider Information | |||||||||
| NPI: | 1093140360 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WIETECHA | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | THOMAS | ||||||||
| NamePrefix: | |||||||||
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| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10 MEDICAL PARK | ||||||||
| Address2: | DENTAL CENTER | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034346567 | ||||||||
| FaxNumber: | 8034346299 | ||||||||
| Practice Location | |||||||||
| Address1: | 10 MEDICAL PARK | ||||||||
| Address2: | DENTAL CENTER | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034346567 | ||||||||
| FaxNumber: | 8034346299 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2013 | ||||||||
| LastUpdateDate: | 09/05/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 8293 | SC | Y | Dental Providers | Dentist |
No ID Information.