Provider Demographics
NPI:1770668840
Name:WISE, CHARLES LEONARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:LEONARD
Last Name:WISE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1910
Mailing Address - Street 2:
Mailing Address - City:MORGAN CITY
Mailing Address - State:LA
Mailing Address - Zip Code:70381-1910
Mailing Address - Country:US
Mailing Address - Phone:985-384-0926
Mailing Address - Fax:985-384-6754
Practice Address - Street 1:1200 VICTOR II BLVD
Practice Address - Street 2:
Practice Address - City:MORGAN CITY
Practice Address - State:LA
Practice Address - Zip Code:70380-1350
Practice Address - Country:US
Practice Address - Phone:985-384-0926
Practice Address - Fax:985-384-6754
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA16711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice