Healthcare Provider Details

I. General information

NPI: 1285642819
Provider Name (Legal Business Name): JEFFERY SCOTT WISENER D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 N 13TH ST
ROGERS AR
72756-3434
US

IV. Provider business mailing address

620 N 13TH ST
ROGERS AR
72756-3434
US

V. Phone/Fax

Practice location:
  • Phone: 479-636-7100
  • Fax: 479-621-6766
Mailing address:
  • Phone: 479-636-7100
  • Fax: 479-621-6766

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number3226
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: