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General NPI Number Information
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NPI Number | 1063300358
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Entity Type | Individual
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Provider Name | JONATHAN WISER
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Gender | Male
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Dates
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Enumeration Date | 06/25/2025
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Last Update Date | 06/25/2025
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Provider Practice Location Address
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Address Line | 860 LYNN ST
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City | LEBANON
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State | MO
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Zip | 65536-3810
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Country | US
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Telephone | 417-334-8337
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Fax |
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Provider Business Mailing Address
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Address Line | 426 COBB DR
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City | LEBANON
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State | MO
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Zip | 65536
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Country | US
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Telephone | 480-652-0846
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 2025020240
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License Number State | MO
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