MEDICARE: DR. SAMUEL PAUL WISE DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	21951	OH

General Provider Information

NPI Number	:	1417934100
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SAMUEL PAUL WISE DDS

Provider Business Mailing Address
First Line	:	9163 HUNTERS CHASE ST NW
Second Line	:
City	:	MASSILLON
State	:	OH
Zip	:	44646-9560
Country	:	US
Telephone Number	:	614-208-1984
Fax Number	:

Provider Business Practice Location Address
First Line	:	6529 FRANK AVE NW
Second Line	:
City	:	NORTH CANTON
State	:	OH
Zip	:	44720-7265
Country	:	US
Telephone Number	:	330-433-1000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/23/2005
Last Update Date	:	01/03/2013

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