MEDICARE: JUSTIN BRADLEY WISE DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	12013460A	IN

General Provider Information

NPI Number	:	1902417454
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUSTIN BRADLEY WISE DMD

Provider Business Mailing Address
First Line	:	59 OAK TRCE
Second Line	:
City	:	CAMPBELLSVILLE
State	:	KY
Zip	:	42718-9528
Country	:	US
Telephone Number	:	270-403-8480
Fax Number	:

Provider Business Practice Location Address
First Line	:	1019 W EADS PKWY
Second Line	:
City	:	LAWRENCEBURG
State	:	IN
Zip	:	47025-1162
Country	:	US
Telephone Number	:	812-496-5828
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/10/2020
Last Update Date	:	08/10/2020

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