Provider Demographics
NPI:1548499635
Name:WISE, JOHN DAVID (DMD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:DAVID
Last Name:WISE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:B 2817 REILLY RD
Mailing Address - Street 2:
Mailing Address - City:FORT BRAGG
Mailing Address - State:NC
Mailing Address - Zip Code:28310-7302
Mailing Address - Country:US
Mailing Address - Phone:910-643-2196
Mailing Address - Fax:
Practice Address - Street 1:B 2817 REILLY RD
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:NC
Practice Address - Zip Code:28310-7302
Practice Address - Country:US
Practice Address - Phone:910-643-2196
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-09
Last Update Date:2013-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC46011223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist