Provider Demographics
NPI:1811157373
Name:WISE, ANDREW R (DDS)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:R
Last Name:WISE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2514 WARM SPRING LN
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96003-6606
Mailing Address - Country:US
Mailing Address - Phone:530-339-6750
Mailing Address - Fax:
Practice Address - Street 1:2540 SISTER MARY COLUMBA DR
Practice Address - Street 2:
Practice Address - City:RED BLUFF
Practice Address - State:CA
Practice Address - Zip Code:96080-4327
Practice Address - Country:US
Practice Address - Phone:530-690-2778
Practice Address - Fax:530-690-2229
Is Sole Proprietor?:No
Enumeration Date:2008-06-09
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45790122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist