Provider Demographics
NPI:1205045903
Name:FISSEL, DONALD BRENT (DDS)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:BRENT
Last Name:FISSEL
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 1:112 S KIBLER ST
Mailing Address - Street 2:
Mailing Address - City:NEW WASHINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:44854-9301
Mailing Address - Country:US
Mailing Address - Phone:419-492-2024
Mailing Address - Fax:419-492-2024
Practice Address - Street 1:112 S KIBLER ST
Practice Address - Street 2:
Practice Address - City:NEW WASHINGTON
Practice Address - State:OH
Practice Address - Zip Code:44854-9301
Practice Address - Country:US
Practice Address - Phone:419-492-2024
Practice Address - Fax:419-492-2024
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.0188481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0709004Medicaid