Healthcare Provider Details

I. General information

NPI: 1740266170
Provider Name (Legal Business Name): JOHN EDWARD BISSELL D.D.S., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8405 W FOREST HOME AVE
GREENFIELD WI
53228-3407
US

IV. Provider business mailing address

634 RIVERWOOD LN
WEST BEND WI
53095-4395
US

V. Phone/Fax

Practice location:
  • Phone: 414-425-7710
  • Fax: 414-425-7424
Mailing address:
  • Phone: 262-334-2881
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number07983
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number6021-015
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: