Provider Demographics
NPI:1780765404
Name:WISE, JOHN MICHAEL (DDS MS)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MICHAEL
Last Name:WISE
Suffix:
Gender:M
Credentials:DDS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:985 RUSSELL AVENUE
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20879
Mailing Address - Country:US
Mailing Address - Phone:301-926-2928
Mailing Address - Fax:301-926-1802
Practice Address - Street 1:985 RUSSELL AVENUE
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20879
Practice Address - Country:US
Practice Address - Phone:301-926-2928
Practice Address - Fax:301-926-1802
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD108851223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
U44081Medicare UPIN
MDWI136071Medicare ID - Type Unspecified