Provider Demographics
NPI:1487057311
Name:JIA-MAHASAP, WISSANEE (DDS,MS,FACP)
Entity type:Individual
Prefix:
First Name:WISSANEE
Middle Name:
Last Name:JIA-MAHASAP
Suffix:
Gender:F
Credentials:DDS,MS,FACP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 CAMERON ST APT 301
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02445-7667
Mailing Address - Country:US
Mailing Address - Phone:617-581-8954
Mailing Address - Fax:
Practice Address - Street 1:188 LONGWOOD AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5819
Practice Address - Country:US
Practice Address - Phone:617-432-1434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-07
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADF1000621223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics