Kerollos Wissa

Primary specialty

DentistTaxonomy code 122300000X

License

DN29645 Issued in FL

Practice address

635 Albany St
Boston, MA 02118-3550

Phone

(617) 358-8300

NPI assigned

Mar 11, 2024

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

Networks

• Freedom Health HMO Network

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1710115200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1728000000000",
    "number": "1376301697",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1461 TERRA VERDE WAY",
            "city": "OCOEE",
            "state": "FL",
            "postal_code": "347618467",
            "telephone_number": "857-395-1771"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "635 ALBANY ST",
            "city": "BOSTON",
            "state": "MA",
            "postal_code": "021183550",
            "telephone_number": "617-358-8300"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "1617 Catalina Blvd",
            "address_purpose": "LOCATION",
            "city": "Deltona",
            "state": "FL",
            "postal_code": "327259699",
            "country_code": "US",
            "telephone_number": "386-457-4520",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "WISSA",
        "first_name": "KEROLLOS",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2024-03-11",
        "last_updated": "2024-10-04",
        "certification_date": "2024-10-04",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "FL",
            "license": "DN29645",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Ash Wismar
• Amy Elizabeth Wisnewski, PA-C
• Cheryl Wisniewski
• Kelly R Wisniewski, PA-C
• Bram Peter Wispelwey, M.D., M.S.
• Anna K. Wiste, MD, PHD
• Victoria Witczak, PA-C
• Margaret Embury Witek, CRNA
• Sara Witek, AU.D
• Lisa Witham, CRNA

• Dentist in Boston, MA
• Providers in Boston, MA by specialty
• Dentist in Massachusetts

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 4, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.