Provider Demographics
NPI:1740402981
Name:WISE, RAY NORMAN (DMD)
Entity type:Individual
Prefix:DR
First Name:RAY
Middle Name:NORMAN
Last Name:WISE
Suffix:
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 1:303 E WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:PA
Mailing Address - Zip Code:17042-5648
Mailing Address - Country:US
Mailing Address - Phone:717-273-7162
Mailing Address - Fax:717-273-1999
Practice Address - Street 1:303 E WALNUT ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17042-5648
Practice Address - Country:US
Practice Address - Phone:717-273-7162
Practice Address - Fax:717-273-1999
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADSO15738L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA61777OtherUNITED CONCORDIA