Provider Demographics
NPI:1235260068
Name:WISE, RAYMOND JOHN (DDS)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:JOHN
Last Name:WISE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 PARK PLZ
Mailing Address - Street 2:
Mailing Address - City:LEE
Mailing Address - State:MA
Mailing Address - Zip Code:01238-1727
Mailing Address - Country:US
Mailing Address - Phone:413-243-1222
Mailing Address - Fax:413-243-3915
Practice Address - Street 1:31 PARK PLZ
Practice Address - Street 2:
Practice Address - City:LEE
Practice Address - State:MA
Practice Address - Zip Code:01238-1727
Practice Address - Country:US
Practice Address - Phone:413-243-1222
Practice Address - Fax:413-243-3915
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA147991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice