Provider Demographics
NPI:1194834895
Name:JANISSE, ROBERT C (DDS)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:C
Last Name:JANISSE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2615 N 4TH ST STE 6
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004-1812
Mailing Address - Country:US
Mailing Address - Phone:928-774-4761
Mailing Address - Fax:
Practice Address - Street 1:7012 NE 40TH ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-3052
Practice Address - Country:US
Practice Address - Phone:360-254-5254
Practice Address - Fax:360-944-3835
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD77911223G0001X
WADE000092521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0158867OtherL&I
WA5038989Medicaid
WA8932835OtherCRIME VICTIMS