Provider Demographics
NPI:1861429888
Name:WIEDEN, DAVID WILLIAM (DC)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:WILLIAM
Last Name:WIEDEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:741 EAGLE RIDGE TRL
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-9120
Mailing Address - Country:US
Mailing Address - Phone:651-430-3065
Mailing Address - Fax:
Practice Address - Street 1:324 5TH AVE N
Practice Address - Street 2:
Practice Address - City:BAYPORT
Practice Address - State:MN
Practice Address - Zip Code:55003-1201
Practice Address - Country:US
Practice Address - Phone:651-439-7621
Practice Address - Fax:651-439-6042
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1432111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor