MEDICARE: DR. JOHN EDWARD BISSELL D.D.S., M.S.

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	1223P0300X	Periodontics	07983	IA
2	1223P0300X	Periodontics	6021-015	WI

General Provider Information

NPI Number	:	1740266170
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN EDWARD BISSELL D.D.S., M.S.

Provider Business Mailing Address
First Line	:	634 RIVERWOOD LN
Second Line	:
City	:	WEST BEND
State	:	WI
Zip	:	53095-4395
Country	:	US
Telephone Number	:	262-334-2881
Fax Number	:

Provider Business Practice Location Address
First Line	:	8405 W FOREST HOME AVE
Second Line	:
City	:	GREENFIELD
State	:	WI
Zip	:	53228-3407
Country	:	US
Telephone Number	:	414-425-7710
Fax Number	:	414-425-7424

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/18/2005
Last Update Date	:	07/08/2007

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