Provider Demographics
NPI:1952325417
Name:HISSONG, BRANDON J (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:J
Last Name:HISSONG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:806 W BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:IL
Mailing Address - Zip Code:61856-1038
Mailing Address - Country:US
Mailing Address - Phone:217-762-7175
Mailing Address - Fax:217-762-7845
Practice Address - Street 1:806 W BRIDGE ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:IL
Practice Address - Zip Code:61856-1038
Practice Address - Country:US
Practice Address - Phone:217-762-7175
Practice Address - Fax:217-762-7845
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist