Provider Demographics
NPI:1245088970
Name:WISEMAN, ANNIE (DMD)
Entity type:Individual
Prefix:
First Name:ANNIE
Middle Name:
Last Name:WISEMAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:424 ROSLYN
Mailing Address - Street 2:
Mailing Address - City:WESTMOUNT
Mailing Address - State:QC
Mailing Address - Zip Code:H3Y2T5
Mailing Address - Country:CA
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:234 E 149TH ST
Practice Address - Street 2:5C-ROOM 337
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10451
Practice Address - Country:US
Practice Address - Phone:718-579-6476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-08
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program