Provider Demographics
NPI:1679276026
Name:WISE, RYAN WILLIAM (DDS)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:WILLIAM
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 1:9532 GREAT SMOKEY AVE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70814-4103
Mailing Address - Country:US
Mailing Address - Phone:225-892-4909
Mailing Address - Fax:
Practice Address - Street 1:9532 GREAT SMOKEY AVE
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70814-4103
Practice Address - Country:US
Practice Address - Phone:225-892-4909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-24
Last Update Date:2023-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALD.007187-C1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist