Provider Demographics
NPI:1740266170
Name:BISSELL, JOHN EDWARD (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:EDWARD
Last Name:BISSELL
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:634 RIVERWOOD LN
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-4395
Mailing Address - Country:US
Mailing Address - Phone:262-334-2881
Mailing Address - Fax:
Practice Address - Street 1:8405 W FOREST HOME AVE
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53228-3407
Practice Address - Country:US
Practice Address - Phone:414-425-7710
Practice Address - Fax:414-425-7424
Is Sole Proprietor?:No
Enumeration Date:2005-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA079831223P0300X
WI6021-0151223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics