Provider Demographics
NPI:1376647487
Name:WISDOM, SIDNEY CHARLES (DDS MS)
Entity Type:Individual
Prefix:
First Name:SIDNEY
Middle Name:CHARLES
Last Name:WISDOM
Suffix:
Gender:M
Credentials:DDS MS
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2350 PROFESSIONAL DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661
Mailing Address - Country:US
Mailing Address - Phone:916-783-5239
Mailing Address - Fax:916-783-5863
Practice Address - Street 1:2350 PROFESSIONAL DR
Practice Address - Street 2:SUITE 300
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661
Practice Address - Country:US
Practice Address - Phone:916-783-5239
Practice Address - Fax:916-783-5863
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA338771223X0400X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist