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General NPI Number Information
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NPI Number | 1528503786
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Entity Type | Organization
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Legal Business Name | JACOB J. BISSONETTE DDS, LLC
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Dates
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Enumeration Date | 12/27/2016
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Last Update Date | 12/27/2016
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Provider Practice Location Address
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Address Line | 1045 JEFFERSON ST STE A
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City | GREENFIELD
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State | OH
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Zip | 45123-8428
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Country | US
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Telephone | 937-242-6677
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Fax | 937-203-3994
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Provider Business Mailing Address
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Address Line | 1045 JEFFERSON ST STE A
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City | GREENFIELD
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State | OH
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Zip | 45123-8428
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Country | US
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Telephone | 937-242-6677
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Fax | 937-203-3994
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Authorized Official
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Title or Position | OWNER/OPERATOR
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Name | DR. JACOB JOSEPH BISSONETTE
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Credential | DDS
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Telephone | 937-242-6677
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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 | 30022616
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License Number State | OH
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