Provider Demographics
NPI:1033276373
Name:KISSNER, THOMAS
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:
Last Name:KISSNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2476 S ONEIDA ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-5289
Mailing Address - Country:US
Mailing Address - Phone:920-065-0764
Mailing Address - Fax:920-965-0807
Practice Address - Street 1:2476 S ONEIDA ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-5289
Practice Address - Country:US
Practice Address - Phone:920-965-0764
Practice Address - Fax:920-965-0807
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2008-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI49761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice