Provider Demographics
NPI:1912998022
Name:WISSE, DAVID RAY
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:RAY
Last Name:WISSE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:QUARRYVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17566-1138
Mailing Address - Country:US
Mailing Address - Phone:717-786-2746
Mailing Address - Fax:717-786-4872
Practice Address - Street 1:316 W 4TH ST
Practice Address - Street 2:
Practice Address - City:QUARRYVILLE
Practice Address - State:PA
Practice Address - Zip Code:17566-1138
Practice Address - Country:US
Practice Address - Phone:717-786-2746
Practice Address - Fax:717-786-4872
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS025597L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice