Provider Demographics
NPI:1154385185
Name:WISE, DAVID PAUL (MD, DDS)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:PAUL
Last Name:WISE
Suffix:
Gender:M
Credentials:MD, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 MORRIS ST SUITE 309
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-1953
Mailing Address - Country:US
Mailing Address - Phone:304-388-3290
Mailing Address - Fax:304-388-3186
Practice Address - Street 1:415 MORRIS ST STE 309
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-1853
Practice Address - Country:US
Practice Address - Phone:304-388-3290
Practice Address - Fax:304-388-3186
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV18520204E00000X
WV33281223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0047377-001Medicaid
WV0047377000Medicaid
850000198OtherRAILROAD MEDICARE
850000198Medicare PIN
F95740Medicare UPIN
850000198OtherRAILROAD MEDICARE