Provider Demographics
NPI:1790075166
Name:WISE DENTISTRY FOR KIDS, PSC
Entity Type:Organization
Organization Name:WISE DENTISTRY FOR KIDS, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:
Authorized Official - Last Name:WISE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:270-469-1403
Mailing Address - Street 1:105 MEDICAL PARK DRIVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CAMPBELLSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42718
Mailing Address - Country:US
Mailing Address - Phone:270-469-1403
Mailing Address - Fax:270-469-1405
Practice Address - Street 1:105 MEDICAL PARK DR
Practice Address - Street 2:SUITE 1
Practice Address - City:CAMPBELLSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42718-9622
Practice Address - Country:US
Practice Address - Phone:270-469-1403
Practice Address - Fax:270-469-1405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-19
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY82541223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty