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General NPI Number Information
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NPI Number | 1548260854
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Entity Type | Individual
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Provider Name | RANDALL STEPHEN WISE DDS
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Gender | Male
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Dates
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Enumeration Date | 07/28/2005
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Last Update Date | 12/16/2014
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Provider Practice Location Address
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Address Line | 7373 W JEFFERSON AVE STE 305
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City | LAKEWOOD
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State | CO
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Zip | 80235-2038
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Country | US
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Telephone | 303-985-1263
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Fax | 303-985-1659
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Provider Business Mailing Address
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Address Line | 7373 W JEFFERSON AVE STE 305
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City | LAKEWOOD
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State | CO
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Zip | 80235-2038
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Country | US
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Telephone | 303-985-1263
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Fax | 303-985-1659
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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 | HDL809
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License Number State | CO
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