Provider Demographics
NPI:1972101277
Name:WISEMAN ENDODONTICS LLC
Entity Type:Organization
Organization Name:WISEMAN ENDODONTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:CHRISTOPHER
Authorized Official - Last Name:PEDURAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-277-7877
Mailing Address - Street 1:5110 W 26TH ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57106-3520
Mailing Address - Country:US
Mailing Address - Phone:605-205-1055
Mailing Address - Fax:
Practice Address - Street 1:5110 W 26TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57106-3520
Practice Address - Country:US
Practice Address - Phone:605-205-1055
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-09
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty