Provider Demographics
NPI:1528503786
Name:JACOB J. BISSONETTE DDS, LLC
Entity type:Organization
Organization Name:JACOB J. BISSONETTE DDS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:BISSONETTE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:937-242-6677
Mailing Address - Street 1:1045 JEFFERSON ST STE A
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45123-8428
Mailing Address - Country:US
Mailing Address - Phone:937-242-6677
Mailing Address - Fax:937-203-3994
Practice Address - Street 1:1045 JEFFERSON ST STE A
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:OH
Practice Address - Zip Code:45123-8428
Practice Address - Country:US
Practice Address - Phone:937-242-6677
Practice Address - Fax:937-203-3994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-27
Last Update Date:2016-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30022616122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty