Healthcare Provider Details

I. General information

NPI: 1790182822
Provider Name (Legal Business Name): WISWALL ENDODONTICS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2014
Last Update Date: 12/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2333 W 57TH ST STE 103
SIOUX FALLS SD
57108-5053
US

IV. Provider business mailing address

2333 W 57TH ST STE 103
SIOUX FALLS SD
57108-5053
US

V. Phone/Fax

Practice location:
  • Phone: 605-789-2017
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberD0827
License Number StateSD

VIII. Authorized Official

Name: DR. ANDREW T WISWALL
Title or Position: PRESIDENT
Credential: DDS
Phone: 605-789-2017