Provider Demographics
NPI:1639153430
Name:WISE, EDWARD MCCRAY JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:MCCRAY
Last Name:WISE
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:112 SALUDA RIDGE CT STE 400
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29169-3461
Mailing Address - Country:US
Mailing Address - Phone:803-796-5791
Mailing Address - Fax:803-796-6486
Practice Address - Street 1:112 SALUDA RIDGE CT STE 400
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-3461
Practice Address - Country:US
Practice Address - Phone:803-796-5791
Practice Address - Fax:803-796-6486
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-05
Last Update Date:2018-03-26
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
SC4120122300000X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist