Provider Demographics
NPI:1063622033
Name:WISENER, STEVEN (DDS)
Entity type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:
Last Name:WISENER
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 1:29580 YOSEMITE SPRINGS PKWY
Mailing Address - Street 2:SUITE C
Mailing Address - City:COARSEGOLD
Mailing Address - State:CA
Mailing Address - Zip Code:93614-8840
Mailing Address - Country:US
Mailing Address - Phone:559-658-7474
Mailing Address - Fax:559-658-7475
Practice Address - Street 1:29580 YOSEMITE SPRINGS PKWY
Practice Address - Street 2:SUITE C
Practice Address - City:COARSEGOLD
Practice Address - State:CA
Practice Address - Zip Code:93614-8840
Practice Address - Country:US
Practice Address - Phone:559-658-7474
Practice Address - Fax:559-658-7475
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADS-26246122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist