Provider Demographics
NPI:1659036739
Name:WISELEY, TERRA L
Entity Type:Individual
Prefix:
First Name:TERRA
Middle Name:L
Last Name:WISELEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3461 MANORWAY RD
Mailing Address - Street 2:
Mailing Address - City:OSSEO
Mailing Address - State:MI
Mailing Address - Zip Code:49266-9833
Mailing Address - Country:US
Mailing Address - Phone:517-320-3175
Mailing Address - Fax:
Practice Address - Street 1:122 HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-9164
Practice Address - Country:US
Practice Address - Phone:517-740-7422
Practice Address - Fax:517-315-4918
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-03
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902011222124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist