Healthcare Provider Details

I. General information

NPI: 1881760148
Provider Name (Legal Business Name): CHAD W WISE D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 06/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 DEBARTOLO PL
BOARDMAN OH
44512-7014
US

IV. Provider business mailing address

99 DEBARTOLO PL
BOARDMAN OH
44512-7014
US

V. Phone/Fax

Practice location:
  • Phone: 330-758-2348
  • Fax: 330-758-0481
Mailing address:
  • Phone: 330-758-2348
  • Fax: 330-758-0481

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number031655
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number30-022975
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: