MEDICARE: WISWALL ADAMS ENDODONTICS LLC

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	1223E0200X	Endodontics	M967	SD

General Provider Information

NPI Number	:	1386013688
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WISWALL ADAMS ENDODONTICS LLC

Provider Business Mailing Address
First Line	:	2525 W MAIN ST STE 206
Second Line	:
City	:	RAPID CITY
State	:	SD
Zip	:	57702-2439
Country	:	US
Telephone Number	:	605-716-3546
Fax Number	:

Provider Business Practice Location Address
First Line	:	2525 W MAIN ST STE 307
Second Line	:
City	:	RAPID CITY
State	:	SD
Zip	:	57702-2443
Country	:	US
Telephone Number	:	605-716-3546
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JEFFREY WISWALL
Credential	:	DDS, MS
Telephone Number	:	605-716-3546

Provider Enumeration Date	:	09/17/2015
Last Update Date	:	09/17/2015

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