Provider Demographics
NPI:1164648010
Name:SIMKINS-WISEMAN, OCTAVIA S (DDS)
Entity Type:Individual
Prefix:DR
First Name:OCTAVIA
Middle Name:S
Last Name:SIMKINS-WISEMAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12150 ANNAPOLIS RD
Mailing Address - Street 2:SUITE301
Mailing Address - City:GLENN DALE
Mailing Address - State:MD
Mailing Address - Zip Code:20769-9183
Mailing Address - Country:US
Mailing Address - Phone:301-249-8000
Mailing Address - Fax:301-249-4958
Practice Address - Street 1:12150 ANNAPOLIS RD
Practice Address - Street 2:SUITE301
Practice Address - City:GLENN DALE
Practice Address - State:MD
Practice Address - Zip Code:20769-9183
Practice Address - Country:US
Practice Address - Phone:301-249-8000
Practice Address - Fax:301-249-4958
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD109831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD10983OtherSTATE LICENSE