Provider Demographics
NPI:1790966695
Name:BISELY, JEFFREY JOHN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:JOHN
Last Name:BISELY
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:CALIFORNIA MEN'S COLONY DENTAL DEPARTMENT
Mailing Address - Street 2:HIGHWAY 1
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93409-0001
Mailing Address - Country:US
Mailing Address - Phone:805-547-7857
Mailing Address - Fax:
Practice Address - Street 1:CALIFORNIA MEN'S COLONY DENTAL DEPARTMENT
Practice Address - Street 2:HIGHWAY 1
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93409-0001
Practice Address - Country:US
Practice Address - Phone:805-547-7857
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-19
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32693122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist