Provider Demographics
NPI:1174726145
Name:WEIDEMANN, JONATHAN WALTER (DDS)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:WALTER
Last Name:WEIDEMANN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 CHILDS WAY
Mailing Address - Street 2:#703
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90815-0277
Mailing Address - Country:US
Mailing Address - Phone:562-431-1183
Mailing Address - Fax:
Practice Address - Street 1:5963 EAST SPRING STREET
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90808
Practice Address - Country:US
Practice Address - Phone:562-421-8401
Practice Address - Fax:562-421-4069
Is Sole Proprietor?:No
Enumeration Date:2007-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45538122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist