Provider Demographics
NPI:1497842801
Name:BRIAN T WISWALL DDS PC
Entity Type:Organization
Organization Name:BRIAN T WISWALL DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:T
Authorized Official - Last Name:WISWALL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:605-373-0245
Mailing Address - Street 1:518 N SYCAMORE AVENUE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57110-5737
Mailing Address - Country:US
Mailing Address - Phone:605-373-0245
Mailing Address - Fax:605-336-3261
Practice Address - Street 1:518 N SYCAMORE AVENUE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57110-5737
Practice Address - Country:US
Practice Address - Phone:605-373-0245
Practice Address - Fax:605-336-3261
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDM4461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty