Provider Demographics
NPI:1417934100
Name:WISE, SAMUEL PAUL (DDS)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:PAUL
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 1:9163 HUNTERS CHASE ST NW
Mailing Address - Street 2:
Mailing Address - City:MASSILLON
Mailing Address - State:OH
Mailing Address - Zip Code:44646-9560
Mailing Address - Country:US
Mailing Address - Phone:614-208-1984
Mailing Address - Fax:
Practice Address - Street 1:6529 FRANK AVE NW
Practice Address - Street 2:
Practice Address - City:NORTH CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720-7265
Practice Address - Country:US
Practice Address - Phone:330-433-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH21951122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist