Healthcare Provider Details

I. General information

NPI: 1952158909
Provider Name (Legal Business Name): WISE OMFS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2024
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 KORNEGAY DR
PRATTVILLE AL
36066-7715
US

IV. Provider business mailing address

711 KORNEGAY DR
PRATTVILLE AL
36066-7715
US

V. Phone/Fax

Practice location:
  • Phone: 334-285-7111
  • Fax:
Mailing address:
  • Phone: 334-325-5810
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State

VIII. Authorized Official

Name: DHARTI PATEL
Title or Position: CLINICAL OPS & BUSINESS DEVELOPMENT
Credential:
Phone: 973-722-3327