Provider Demographics
NPI:1427096106
Name:WISNIEWSKI, CHARLES ADAM (DMD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:ADAM
Last Name:WISNIEWSKI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:722 HUNTINGDON PIKE
Mailing Address - Street 2:
Mailing Address - City:JENKINTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19046-4461
Mailing Address - Country:US
Mailing Address - Phone:215-379-2060
Mailing Address - Fax:215-379-0386
Practice Address - Street 1:722 HUNTINGDON PIKE
Practice Address - Street 2:
Practice Address - City:JENKINTOWN
Practice Address - State:PA
Practice Address - Zip Code:19046-4461
Practice Address - Country:US
Practice Address - Phone:215-379-2060
Practice Address - Fax:215-379-0386
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS024093L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice