Provider Demographics
NPI:1124111935
Name:WISE, LARRY A (DDS)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:A
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 1:909 W ESPLANADE AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:KENNER
Mailing Address - State:LA
Mailing Address - Zip Code:70065-2700
Mailing Address - Country:US
Mailing Address - Phone:504-464-0202
Mailing Address - Fax:504-464-0264
Practice Address - Street 1:909 W ESPLANADE AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:KENNER
Practice Address - State:LA
Practice Address - Zip Code:70065-2700
Practice Address - Country:US
Practice Address - Phone:504-464-0202
Practice Address - Fax:504-464-0264
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA27771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice