Provider Demographics
NPI:1851419386
Name:WISEMAN, JERRY W (DDS)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:W
Last Name:WISEMAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9401 SW HIGHWAY 200
Mailing Address - Street 2:SUITE 402
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34481-9612
Mailing Address - Country:US
Mailing Address - Phone:352-873-4222
Mailing Address - Fax:352-873-4232
Practice Address - Street 1:9401 SW HIGHWAY 200
Practice Address - Street 2:SUITE 402
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34481-9612
Practice Address - Country:US
Practice Address - Phone:352-873-4222
Practice Address - Fax:352-873-4232
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL104121223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics