Provider Demographics
NPI:1417442930
Name:WISSLER, DOUGLAS KYLE (DMD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:KYLE
Last Name:WISSLER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1462 SPROULE AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63139-3107
Mailing Address - Country:US
Mailing Address - Phone:309-706-3571
Mailing Address - Fax:
Practice Address - Street 1:7313 WATSON RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63119-4405
Practice Address - Country:US
Practice Address - Phone:314-352-3886
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-27
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018022475122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist