Provider Demographics
NPI:1861619413
Name:BELLISSIMO, JOSEPH JR
Entity type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:
Last Name:BELLISSIMO
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4867 EAGLE ROCK BLVD.
Mailing Address - Street 2:SUITE #B
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90041
Mailing Address - Country:US
Mailing Address - Phone:323-255-0193
Mailing Address - Fax:323-255-9711
Practice Address - Street 1:4867 EAGLE ROCK BLVD.
Practice Address - Street 2:SUITE #B
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90041
Practice Address - Country:US
Practice Address - Phone:323-255-0193
Practice Address - Fax:323-255-9711
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA315671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB31567-01OtherDENTI-CAL