Provider Demographics
NPI:1134233935
Name:WISE, EDWARD M SR (DMD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:M
Last Name:WISE
Suffix:SR
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 1:1090 RIBAUT RD
Mailing Address - Street 2:
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29902-5437
Mailing Address - Country:US
Mailing Address - Phone:843-521-4344
Mailing Address - Fax:843-521-1804
Practice Address - Street 1:1090 RIBAUT RD
Practice Address - Street 2:
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29902-5437
Practice Address - Country:US
Practice Address - Phone:843-521-4344
Practice Address - Fax:843-521-1804
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCZ17771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
826791OtherUCCI
SCZ17777Medicaid