Provider Demographics
NPI:1417416728
Name:WISE, SAM (DDS, MOM, MSC, MDS)
Entity Type:Individual
Prefix:PROF
First Name:SAM
Middle Name:
Last Name:WISE
Suffix:
Gender:M
Credentials:DDS, MOM, MSC, MDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1256 TIMBER LN
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75036-1743
Mailing Address - Country:US
Mailing Address - Phone:973-747-6425
Mailing Address - Fax:
Practice Address - Street 1:3045 N GOLIAD ST STE 105
Practice Address - Street 2:
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75087-7097
Practice Address - Country:US
Practice Address - Phone:972-722-9100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-16
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX35081122300000X, 1223G0001X, 1223S0112X, 1223X2210X, 1223X2210X
WA607957141223G0001X, 1223S0112X, 1223X2210X
WADE607957141223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X2210XDental ProvidersDentistOrofacial Pain
No122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1487398285OtherNPI II
1518520170OtherNPI II