Provider Demographics
NPI:1881670560
Name:WISWALL, F. HERBERT (DDS)
Entity Type:Individual
Prefix:
First Name:F. HERBERT
Middle Name:
Last Name:WISWALL
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 1:600 4TH ST NE
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:SD
Mailing Address - Zip Code:57201-1898
Mailing Address - Country:US
Mailing Address - Phone:605-886-8096
Mailing Address - Fax:605-886-1979
Practice Address - Street 1:600 4TH ST NE
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:SD
Practice Address - Zip Code:57201-1898
Practice Address - Country:US
Practice Address - Phone:605-886-8096
Practice Address - Fax:605-886-1979
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDM-3681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD7800510Medicaid