Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223S0112X | Oral and Maxillofacial Surgeon | 2148 | SC |
NPI | 1114092707 |
---|---|
Provider Name | Dr. Scott C Wietecha |
First Address | Columbia, SC 29212-1179 |
Second Address | Columbia, SC 29212-1179 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/11/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
2148 | DENTAL LICENSE (01) | SC |
T24843 | (02) | SC |
ZZ2148 | (05) | SC |