Provider Demographics
NPI:1780645804
Name:GISSAL, JOHN R (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:R
Last Name:GISSAL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:3801 GLENKERRY CT
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-0718
Mailing Address - Country:US
Mailing Address - Phone:269-323-1527
Mailing Address - Fax:269-323-1670
Practice Address - Street 1:3801 GLENKERRY CT
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-0718
Practice Address - Country:US
Practice Address - Phone:269-323-1527
Practice Address - Fax:269-323-1670
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2010-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010129661223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1644808Medicaid
MI2990946Medicaid
T34002Medicare UPIN