Organization
TESLA DENTAL IMPLANT LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
PROF. SAM WISE DDS, MOM, MSC, MDS (OWNER)
(973) 747-6425
Entity
Organization
Contact information
Practice address
151 RIDGE POINT PKWY STE 400, KELLER, TX 76248-8801
(817) 835-6955
Mailing address
5605 FM 423, SUIT 500 #410, FRISCO, TX 75036
(973) 747-6425
Taxonomy
Speciality
Code
Description
License number
State
1223X2210X
Orofacial Pain Dentistry
Primary
—
—
261QD0000X
Dental Clinic/Center
—
—
261QR0200X
Radiology Clinic/Center
—
—
261QS0112X
Oral and Maxillofacial Surgery Clinic/Center
—
—
261QS1200X
Sleep Disorder Diagnostic Clinic/Center
—
—
292200000X
Dental Laboratory
—
—
Other
Enumeration date
04/27/2022
Last updated
04/27/2022
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