Provider Demographics
NPI:1982816500
Name:WISE, ROGER J (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:J
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 1:90 HUMPHREY ST
Mailing Address - Street 2:
Mailing Address - City:SWAMPSCOTT
Mailing Address - State:MA
Mailing Address - Zip Code:01907-2542
Mailing Address - Country:US
Mailing Address - Phone:781-596-2220
Mailing Address - Fax:781-598-8050
Practice Address - Street 1:90 HUMPHREY ST
Practice Address - Street 2:
Practice Address - City:SWAMPSCOTT
Practice Address - State:MA
Practice Address - Zip Code:01907-2542
Practice Address - Country:US
Practice Address - Phone:781-596-2220
Practice Address - Fax:781-598-8050
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA116621223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics