Provider Demographics
NPI:1316389117
Name:WISWALL, STEVEN FREDERICK (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:FREDERICK
Last Name:WISWALL
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13170 BRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-8523
Mailing Address - Country:US
Mailing Address - Phone:605-868-6422
Mailing Address - Fax:
Practice Address - Street 1:703 QUINCY ST STE 2
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-3674
Practice Address - Country:US
Practice Address - Phone:605-868-6422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-22
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDD10701223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics