Provider Demographics
NPI:1568511640
Name:BISARO, FRED M (DDS)
Entity Type:Individual
Prefix:DR
First Name:FRED
Middle Name:M
Last Name:BISARO
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 1:1680 KINGSWAY CT
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48183-1957
Mailing Address - Country:US
Mailing Address - Phone:734-675-2510
Mailing Address - Fax:734-675-7130
Practice Address - Street 1:1680 KINGSWAY CT
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:MI
Practice Address - Zip Code:48183-1957
Practice Address - Country:US
Practice Address - Phone:734-675-2510
Practice Address - Fax:734-675-7130
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010124551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice