Healthcare Provider Details

I. General information

NPI: 1871707554
Provider Name (Legal Business Name): ERIK MARK TREMAN WISEMAN DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

719 MAIN AVE
BROOKINGS SD
57006-1426
US

IV. Provider business mailing address

719 MAIN AVE
BROOKINGS SD
57006-1426
US

V. Phone/Fax

Practice location:
  • Phone: 605-692-9555
  • Fax: 605-692-0967
Mailing address:
  • Phone: 605-692-9555
  • Fax: 605-692-0967

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD0624
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: