Healthcare Provider Details

I. General information

NPI: 1265582712
Provider Name (Legal Business Name): BENJAMIN T. BISSELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 11/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

575 SIOUX POINT ROAD
DAKOTA DUNES SD
57049-5312
US

IV. Provider business mailing address

575 SIOUX POINT ROAD
DAKOTA DUNES SD
57049-5312
US

V. Phone/Fax

Practice location:
  • Phone: 605-217-2667
  • Fax: 605-217-2900
Mailing address:
  • Phone: 605-217-2667
  • Fax: 605-217-2900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number25765
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number8925
License Number StateSD
# 3
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number41240
License Number StateIA
# 4
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number25765
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: