Provider Demographics
NPI:1447373220
Name:VANSISTINE, JR., CYRIL JOSEPH (DDS)
Entity type:Individual
Prefix:DR
First Name:CYRIL
Middle Name:JOSEPH
Last Name:VANSISTINE, JR.
Suffix:
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 1:1001 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-2609
Mailing Address - Country:US
Mailing Address - Phone:920-336-2500
Mailing Address - Fax:920-336-3518
Practice Address - Street 1:1001 N BROADWAY
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-2609
Practice Address - Country:US
Practice Address - Phone:920-336-2500
Practice Address - Fax:920-336-3518
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5001499122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist