Provider Demographics
NPI:1053439554
Name:WISE, HEATHER HOOD (DMD)
Entity type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:HOOD
Last Name:WISE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
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Mailing Address - Street 1:105 MEDICAL PARK DR
Mailing Address - Street 2:SUITE #1
Mailing Address - City:CAMPBELLSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42718-9622
Mailing Address - Country:US
Mailing Address - Phone:270-469-1403
Mailing Address - Fax:270-469-1405
Practice Address - Street 1:105 MEDICAL PARK DR
Practice Address - Street 2:SUITE #1
Practice Address - City:CAMPBELLSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42718-9622
Practice Address - Country:US
Practice Address - Phone:270-469-1403
Practice Address - Fax:270-469-1405
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2008-04-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
KY82541223G0001X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223G0001XDental ProvidersDentistGeneral Practice