Provider Demographics
NPI:1902417454
Name:WISE, JUSTIN BRADLEY (DMD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:BRADLEY
Last Name:WISE
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 1:59 OAK TRCE
Mailing Address - Street 2:
Mailing Address - City:CAMPBELLSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42718-9528
Mailing Address - Country:US
Mailing Address - Phone:270-403-8480
Mailing Address - Fax:
Practice Address - Street 1:1019 W EADS PKWY
Practice Address - Street 2:
Practice Address - City:LAWRENCEBURG
Practice Address - State:IN
Practice Address - Zip Code:47025-1162
Practice Address - Country:US
Practice Address - Phone:812-496-5828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-10
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12013460A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist