Provider Demographics
NPI:1669521472
Name:C. MICHAEL WISE DDS PA
Entity type:Organization
Organization Name:C. MICHAEL WISE DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:WISE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:501-268-8634
Mailing Address - Street 1:333 E MARKET AVE
Mailing Address - Street 2:
Mailing Address - City:SEARCY
Mailing Address - State:AR
Mailing Address - Zip Code:72143-5429
Mailing Address - Country:US
Mailing Address - Phone:501-268-8634
Mailing Address - Fax:
Practice Address - Street 1:333 E MARKET AVE
Practice Address - Street 2:
Practice Address - City:SEARCY
Practice Address - State:AR
Practice Address - Zip Code:72143-5429
Practice Address - Country:US
Practice Address - Phone:501-268-8634
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2687261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental