Healthcare Provider Details

I. General information

NPI: 1952325417
Provider Name (Legal Business Name): BRANDON J HISSONG DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 09/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

806 W BRIDGE ST
MONTICELLO IL
61856-1038
US

IV. Provider business mailing address

806 W BRIDGE ST
MONTICELLO IL
61856-1038
US

V. Phone/Fax

Practice location:
  • Phone: 217-762-7175
  • Fax: 217-762-7845
Mailing address:
  • Phone: 217-762-7175
  • Fax: 217-762-7845

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: