Basic Information
| Provider Information | |||||||||
| NPI: | 1518929363 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WISSER | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | J. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 225 E 5TH ST | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485021641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8104064912 | ||||||||
| FaxNumber: | 8104246029 | ||||||||
| Practice Location | |||||||||
| Address1: | G5399 N SAGINAW ST | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485051536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8107850863 | ||||||||
| FaxNumber: | 8107850865 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2006 | ||||||||
| LastUpdateDate: | 10/15/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223P0300X | D10989 040 | MI | Y | Dental Providers | Dentist | Periodontics |
ID Information
| ID | Type | State | Issuer | Description | 382406558 | 01 | MI | TAX ID | OTHER |