Provider Demographics
NPI:1285642819
Name:WISENER, JEFFERY SCOTT (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEFFERY
Middle Name:SCOTT
Last Name:WISENER
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 1:620 N 13TH ST
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72756-3434
Mailing Address - Country:US
Mailing Address - Phone:479-636-7100
Mailing Address - Fax:479-621-6766
Practice Address - Street 1:620 N 13TH ST
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72756-3434
Practice Address - Country:US
Practice Address - Phone:479-636-7100
Practice Address - Fax:479-621-6766
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR32261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5T697OtherBLUECROSS/BLUESHIELD
AR909826OtherUNITED CONCORDIA NUMBER