Healthcare Provider Details

I. General information

NPI: 1134552995
Provider Name (Legal Business Name): DANIEL DAVID HISEROTE JR. D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2013
Last Update Date: 12/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1629 1ST AVE SW
SIOUX CENTER IA
51250-1120
US

IV. Provider business mailing address

1629 1ST AVE SW
SIOUX CENTER IA
51250-1120
US

V. Phone/Fax

Practice location:
  • Phone: 712-722-3216
  • Fax: 712-722-3218
Mailing address:
  • Phone: 712-722-3216
  • Fax: 712-722-3218

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDDS-09048
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: