Provider Demographics
NPI:1477927085
Name:PISANO, JUSTIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:
Last Name:PISANO
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 1:1942 SHERMAN ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-2918
Mailing Address - Country:US
Mailing Address - Phone:734-604-1843
Mailing Address - Fax:
Practice Address - Street 1:429 NW 11TH ST
Practice Address - Street 2:APT 6
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73103-3927
Practice Address - Country:US
Practice Address - Phone:734-604-1843
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-19
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK13181223S0112X
MI29010228581223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery