Provider Demographics
NPI:1285704171
Name:WISEMAN, KRISTIN TERA (DDS)
Entity type:Individual
Prefix:DR
First Name:KRISTIN
Middle Name:TERA
Last Name:WISEMAN
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 1:9920 COULOAK DR
Mailing Address - Street 2:#100
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28216-8925
Mailing Address - Country:US
Mailing Address - Phone:704-392-7676
Mailing Address - Fax:
Practice Address - Street 1:9920 COULOAK DR
Practice Address - Street 2:#100
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28216-8925
Practice Address - Country:US
Practice Address - Phone:704-392-7676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC83121223G0001X
CO104001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice