Healthcare Provider Details

I. General information

NPI: 1154385185
Provider Name (Legal Business Name): DAVID PAUL WISE MD, DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2006
Last Update Date: 06/20/2023
Certification Date: 06/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 MORRIS ST STE 309
CHARLESTON WV
25301-1853
US

IV. Provider business mailing address

415 MORRIS ST SUITE 309
CHARLESTON WV
25301-1953
US

V. Phone/Fax

Practice location:
  • Phone: 304-388-3290
  • Fax: 304-388-3186
Mailing address:
  • Phone: 304-388-3290
  • Fax: 304-388-3186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number3328
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number18520
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: