Healthcare Provider Details

I. General information

NPI: 1780765404
Provider Name (Legal Business Name): JOHN MICHAEL WISE DDS MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

985 RUSSELL AVENUE
GAITHERSBURG MD
20879
US

IV. Provider business mailing address

985 RUSSELL AVENUE
GAITHERSBURG MD
20879
US

V. Phone/Fax

Practice location:
  • Phone: 301-926-2928
  • Fax: 301-926-1802
Mailing address:
  • Phone: 301-926-2928
  • Fax: 301-926-1802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number10885
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: