Provider Demographics
NPI:1699044487
Name:WISE, CONSTANCE CHAMBERLAIN
Entity Type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:CHAMBERLAIN
Last Name:WISE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CONNIE
Other - Middle Name:
Other - Last Name:CHAMBERLAIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:4300 DAYTON BLVD
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37415
Mailing Address - Country:US
Mailing Address - Phone:423-875-5302
Mailing Address - Fax:423-875-0461
Practice Address - Street 1:4300 DAYTON BLVD
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37415
Practice Address - Country:US
Practice Address - Phone:423-875-5302
Practice Address - Fax:423-875-0461
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-22
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN93671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice