Provider Demographics
NPI:1073183893
Name:JANISSE DENTAL INC
Entity type:Organization
Organization Name:JANISSE DENTAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:JANISSE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:925-774-4761
Mailing Address - Street 1:2615 N 4TH ST STE 6
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004-1812
Mailing Address - Country:US
Mailing Address - Phone:928-774-4761
Mailing Address - Fax:
Practice Address - Street 1:2615 N 4TH ST STE 6
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-1812
Practice Address - Country:US
Practice Address - Phone:928-774-4761
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-25
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery