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General NPI Number Information
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NPI Number | 1790182822
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Entity Type | Organization
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Legal Business Name | WISWALL ENDODONTICS PC
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Dates
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Enumeration Date | 12/04/2014
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Last Update Date | 12/04/2014
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Provider Practice Location Address
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Address Line | 2333 W 57TH ST STE 103
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City | SIOUX FALLS
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State | SD
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Zip | 57108-5053
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Country | US
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Telephone | 605-789-2017
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Fax |
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Provider Business Mailing Address
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Address Line | 2333 W 57TH ST STE 103
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City | SIOUX FALLS
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State | SD
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Zip | 57108-5053
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. ANDREW T WISWALL
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Credential | DDS
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Telephone | 605-789-2017
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | D0827
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License Number State | SD
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