Healthcare Provider Details

I. General information

NPI: 1366983843
Provider Name (Legal Business Name): DENNIS JANISSE CPED
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2017
Last Update Date: 03/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2475 N 124TH ST
BROOKFIELD WI
53005-4630
US

IV. Provider business mailing address

2475 N 124TH ST
BROOKFIELD WI
53005-4630
US

V. Phone/Fax

Practice location:
  • Phone: 262-754-2440
  • Fax:
Mailing address:
  • Phone: 262-754-2440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224L00000X
TaxonomyPedorthist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: