Provider Demographics
NPI:1245327642
Name:WISWALL, BRIAN T (DDS)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:T
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 1:518 N SYCAMORE AVENUE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57110-5737
Mailing Address - Country:US
Mailing Address - Phone:605-373-0245
Mailing Address - Fax:605-336-3261
Practice Address - Street 1:518 N SYCAMORE AVENUE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57110-5737
Practice Address - Country:US
Practice Address - Phone:605-373-0245
Practice Address - Fax:605-336-3261
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDM4461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice