Basic Information
Provider Information | |||||||||
NPI: | 1154385185 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WISE | ||||||||
FirstName: | DAVID | ||||||||
MiddleName: | PAUL | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD, DDS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 415 MORRIS ST SUITE 309 | ||||||||
Address2: |   | ||||||||
City: | CHARLESTON | ||||||||
State: | WV | ||||||||
PostalCode: | 253011953 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3043883290 | ||||||||
FaxNumber: | 3043883186 | ||||||||
Practice Location | |||||||||
Address1: | 415 MORRIS ST | ||||||||
Address2: | SUITE 309 | ||||||||
City: | CHARLESTON | ||||||||
State: | WV | ||||||||
PostalCode: | 253011842 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3043883290 | ||||||||
FaxNumber: | 3043883186 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/14/2006 | ||||||||
LastUpdateDate: | 12/18/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 204E00000X | 18520 | WV | Y |   | Allopathic & Osteopathic Physicians | Oral & Maxillofacial Surgery |   | 1223S0112X | 3328 | WV | N |   | Dental Providers | Dentist | Oral and Maxillofacial Surgery |
ID Information
ID | Type | State | Issuer | Description | 0047377000 | 05 | WV |   | MEDICAID | 0047377-001 | 05 | WV |   | MEDICAID | 850000198 | 01 |   | RAILROAD MEDICARE | OTHER |