Healthcare Provider Details

I. General information

NPI: 1548838303
Provider Name (Legal Business Name): JOHN CISMAS DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2021
Last Update Date: 11/18/2024
Certification Date: 11/18/2024
Deactivation Date: 11/13/2024
Reactivation Date: 11/18/2024

III. Provider practice location address

855 E BROWN RD STE 4
MESA AZ
85203-4958
US

IV. Provider business mailing address

855 E BROWN RD STE 4
MESA AZ
85203-4958
US

V. Phone/Fax

Practice location:
  • Phone: 808-346-1004
  • Fax:
Mailing address:
  • Phone: 480-834-6100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD011061
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: