Healthcare Provider Details

I. General information

NPI: 1518520170
Provider Name (Legal Business Name): GERMAN WISE DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2019
Last Update Date: 12/16/2021
Certification Date: 12/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1538 11TH AVE
LONGVIEW WA
98632-4123
US

IV. Provider business mailing address

1538 11TH AVE
LONGVIEW WA
98632-4123
US

V. Phone/Fax

Practice location:
  • Phone: 360-636-3400
  • Fax: 360-578-1277
Mailing address:
  • Phone: 360-636-3400
  • Fax: 360-578-1277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. SAM WISE
Title or Position: OWNER
Credential: DDS, MOM, MSC, MDS.
Phone: 360-636-3400