Provider Demographics
NPI:1740859933
Name:WISE, HEATHER N (DMD)
Entity type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:N
Last Name:WISE
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 1:24370 TIM BRADLEY RD
Mailing Address - Street 2:
Mailing Address - City:SAUCIER
Mailing Address - State:MS
Mailing Address - Zip Code:39574-9660
Mailing Address - Country:US
Mailing Address - Phone:228-234-4066
Mailing Address - Fax:
Practice Address - Street 1:1050 FRONTAGE DR W STE C
Practice Address - Street 2:
Practice Address - City:WIGGINS
Practice Address - State:MS
Practice Address - Zip Code:39577-8357
Practice Address - Country:US
Practice Address - Phone:601-476-6280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-22
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS4225-211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice