Provider Demographics
NPI:1508999616
Name:SISULAK, JON J (DDS,MS)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:J
Last Name:SISULAK
Suffix:
Gender:M
Credentials:DDS,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6160 S 108TH ST
Mailing Address - Street 2:
Mailing Address - City:HALES CORNERS
Mailing Address - State:WI
Mailing Address - Zip Code:53130-2525
Mailing Address - Country:US
Mailing Address - Phone:414-425-2410
Mailing Address - Fax:414-425-9751
Practice Address - Street 1:6160 S 108TH ST
Practice Address - Street 2:
Practice Address - City:HALES CORNERS
Practice Address - State:WI
Practice Address - Zip Code:53130-2525
Practice Address - Country:US
Practice Address - Phone:414-425-2410
Practice Address - Fax:414-425-9751
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI50018461223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics