Provider Demographics
NPI:1689637068
Name:ANDREW R WISE DDS PC
Entity Type:Organization
Organization Name:ANDREW R WISE DDS PC
Other - Org Name:ANDREW R WISE DDS INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:R
Authorized Official - Last Name:WISE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:707-447-8289
Mailing Address - Street 1:1241 ALAMO DR
Mailing Address - Street 2:STE 11
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95687
Mailing Address - Country:US
Mailing Address - Phone:707-447-8289
Mailing Address - Fax:707-447-3769
Practice Address - Street 1:1241 ALAMO DR
Practice Address - Street 2:STE 11
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95687
Practice Address - Country:US
Practice Address - Phone:707-447-8289
Practice Address - Fax:707-447-3769
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA457901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
741169OtherUNITED CONCORDIA