Provider Demographics
NPI:1063592160
Name:WISWALL, JEFFREY HERBERT (DDS, MS)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:HERBERT
Last Name:WISWALL
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 1:2525 W MAIN ST STE 307
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-2443
Mailing Address - Country:US
Mailing Address - Phone:605-716-3546
Mailing Address - Fax:
Practice Address - Street 1:2525 W MAIN ST STE 307
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-2443
Practice Address - Country:US
Practice Address - Phone:605-716-3546
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDM9671223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics