Provider Demographics
NPI:1366593642
Name:WETTACH, MARY HALVERSON (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:HALVERSON
Last Name:WETTACH
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 S. GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:IA
Mailing Address - Zip Code:52641-2600
Mailing Address - Country:US
Mailing Address - Phone:319-385-6750
Mailing Address - Fax:
Practice Address - Street 1:500 S. GRAND AVE
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:IA
Practice Address - Zip Code:52641-2600
Practice Address - Country:US
Practice Address - Phone:319-385-6750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA67391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA187690OtherDELTA DENTAL
IA0187690Medicaid