Provider Demographics
NPI:1710048855
Name:WISMANN, ENRIQUE GABRIEL (DMD)
Entity Type:Individual
Prefix:DR
First Name:ENRIQUE
Middle Name:GABRIEL
Last Name:WISMANN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7600 N 15TH ST STE 170
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-4305
Mailing Address - Country:US
Mailing Address - Phone:602-997-0911
Mailing Address - Fax:
Practice Address - Street 1:7600 N 15TH ST STE 170
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-4305
Practice Address - Country:US
Practice Address - Phone:602-997-0911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6905122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist