MEDICARE: JANISSE DENTAL INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QS0112X	Oral and Maxillofacial Surgery Clinic/Center
2	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1073183893
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JANISSE DENTAL INC

Provider Business Mailing Address
First Line	:	2615 N 4TH ST STE 6
Second Line	:
City	:	FLAGSTAFF
State	:	AZ
Zip	:	86004-1812
Country	:	US
Telephone Number	:	928-774-4761
Fax Number	:

Provider Business Practice Location Address
First Line	:	2615 N 4TH ST STE 6
Second Line	:
City	:	FLAGSTAFF
State	:	AZ
Zip	:	86004-1812
Country	:	US
Telephone Number	:	928-774-4761
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ROBERT JANISSE
Credential	:	DDS
Telephone Number	:	925-774-4761

Provider Enumeration Date	:	06/25/2021
Last Update Date	:	06/25/2021

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