Provider Demographics
NPI:1952346082
Name:HISEL, JOHN EUGENE JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:EUGENE
Last Name:HISEL
Suffix:JR
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 1:10162 W FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8117
Mailing Address - Country:US
Mailing Address - Phone:208-375-0192
Mailing Address - Fax:208-378-7333
Practice Address - Street 1:10162 W FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8117
Practice Address - Country:US
Practice Address - Phone:208-375-0192
Practice Address - Fax:208-378-7333
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD1963122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist