Provider Demographics
NPI:1821158478
Name:HISER, PAUL THOMAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:THOMAS
Last Name:HISER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:P.
Other - Middle Name:THOMAS
Other - Last Name:HISER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:5565 GROSSMONT CENTER DR
Mailing Address - Street 2:SUITE 129
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-3020
Mailing Address - Country:US
Mailing Address - Phone:619-463-4486
Mailing Address - Fax:619-463-6553
Practice Address - Street 1:5565 GROSSMONT CENTER DR
Practice Address - Street 2:SUITE 129
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3020
Practice Address - Country:US
Practice Address - Phone:619-463-4486
Practice Address - Fax:619-463-6553
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA218031223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery