MEDICARE: DR. RANDALL STEPHEN 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	HDL809	CO

General Provider Information

NPI Number	:	1548260854
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RANDALL STEPHEN WISE DDS

Provider Business Mailing Address
First Line	:	7373 W JEFFERSON AVE
Second Line	:	STE 305
City	:	LAKEWOOD
State	:	CO
Zip	:	80235-2038
Country	:	US
Telephone Number	:	303-985-1263
Fax Number	:	303-985-1659

Provider Business Practice Location Address
First Line	:	7373 W JEFFERSON AVE
Second Line	:	STE 305
City	:	LAKEWOOD
State	:	CO
Zip	:	80235-2038
Country	:	US
Telephone Number	:	303-985-1263
Fax Number	:	303-985-1659

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

Provider Enumeration Date	:	07/28/2005
Last Update Date	:	12/16/2014

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