Provider Demographics
NPI:1952514200
Name:SEBASTIAN-WISE, CARLYN M (DDS)
Entity Type:Individual
Prefix:
First Name:CARLYN
Middle Name:M
Last Name:SEBASTIAN-WISE
Suffix:
Gender:F
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:PO BOX 196
Mailing Address - Street 2:
Mailing Address - City:HURON
Mailing Address - State:OH
Mailing Address - Zip Code:44839-0196
Mailing Address - Country:US
Mailing Address - Phone:419-357-2640
Mailing Address - Fax:
Practice Address - Street 1:3416 COLUMBUS AVE
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870-5557
Practice Address - Country:US
Practice Address - Phone:419-625-2454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2011-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-195691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice