1689637068 NPI number — ANDREW R WISE DDS PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689637068 NPI number — ANDREW R WISE DDS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANDREW R WISE DDS PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689637068
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1241 ALAMO DR
Provider Second Line Business Mailing Address:
STE 11
Provider Business Mailing Address City Name:
VACAVILLE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95687
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-447-8289
Provider Business Mailing Address Fax Number:
707-447-3769

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1241 ALAMO DR
Provider Second Line Business Practice Location Address:
STE 11
Provider Business Practice Location Address City Name:
VACAVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95687
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-447-8289
Provider Business Practice Location Address Fax Number:
707-447-3769
Provider Enumeration Date:
04/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WISE
Authorized Official First Name:
ANDREW
Authorized Official Middle Name:
R
Authorized Official Title or Position:
OWNER PRESIDENT
Authorized Official Telephone Number:
707-447-8289

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  45790 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 741169 . This is a "UNITED CONCORDIA" identifier . This identifiers is of the category "OTHER".




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