Provider Demographics
NPI:1134385479
Name:RICHARD L. WIEDOWER, D.D.S., P.A.
Entity type:Organization
Organization Name:RICHARD L. WIEDOWER, D.D.S., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:SANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-327-9988
Mailing Address - Street 1:810 SALEM RD
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-4800
Mailing Address - Country:US
Mailing Address - Phone:501-327-9988
Mailing Address - Fax:501-327-9991
Practice Address - Street 1:810 SALEM RD
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-4800
Practice Address - Country:US
Practice Address - Phone:501-327-9988
Practice Address - Fax:501-327-9991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-06
Last Update Date:2008-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR27041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR150619608Medicaid
AR59167OtherBCBS
AR849711OtherUCCI