Provider Demographics
NPI:1124355292
Name:WISNIESKI, JOSEPH R JR (DDS)
Entity type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:R
Last Name:WISNIESKI
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 1:2650 CAMINO DEL RIO NORTH
Mailing Address - Street 2:STE. 102
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108
Mailing Address - Country:US
Mailing Address - Phone:619-298-0521
Mailing Address - Fax:619-398-0661
Practice Address - Street 1:2650 CAMINO DEL RIO N
Practice Address - Street 2:#102
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108
Practice Address - Country:US
Practice Address - Phone:619-298-0521
Practice Address - Fax:619-398-0661
Is Sole Proprietor?:No
Enumeration Date:2009-11-11
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28896122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist