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General NPI Number Information
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NPI Number | 1336275973
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Entity Type | Organization
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Legal Business Name | CLISSO DENTISTRY PC
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Dates
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Enumeration Date | 02/26/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 807 PARK AVE NE
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City | NORTON
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State | VA
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Zip | 24273
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Country | US
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Telephone | 276-679-6030
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Fax | 276-679-6030
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Provider Business Mailing Address
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Address Line | PO BOX 920
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City | NORTON
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State | VA
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Zip | 24273
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Country | US
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Telephone | 276-679-6030
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Fax | 276-679-6030
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Authorized Official
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Title or Position | OWNER OPERATOR DENTIST
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Name | MONICA LEANN CLISSO
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Credential | DDS
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Telephone | 276-679-6030
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 0401410603
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License Number State | VA
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