Healthcare Provider Details

I. General information

NPI: 1477927085
Provider Name (Legal Business Name): JUSTIN PISANO D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2015
Last Update Date: 12/08/2021
Certification Date: 12/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

429 NW 11TH ST APT 6
OKLAHOMA CITY OK
73103-3927
US

IV. Provider business mailing address

1942 SHERMAN ST SE
GRAND RAPIDS MI
49506-2918
US

V. Phone/Fax

Practice location:
  • Phone: 734-604-1843
  • Fax:
Mailing address:
  • Phone: 734-604-1843
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number1318
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2901022858
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: