Provider Demographics
NPI:1003319260
Name:NISTA FAMILY DENTAL CENTER
Entity Type:Organization
Organization Name:NISTA FAMILY DENTAL CENTER
Other - Org Name:NISTA FAMILY DENTAL CENTER PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:NISTA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:724-733-3762
Mailing Address - Street 1:105 PFEFFER RD STE 2
Mailing Address - Street 2:
Mailing Address - City:EXPORT
Mailing Address - State:PA
Mailing Address - Zip Code:15632-2046
Mailing Address - Country:US
Mailing Address - Phone:724-733-3762
Mailing Address - Fax:724-325-8058
Practice Address - Street 1:105 PFEFFER RD STE 2
Practice Address - Street 2:
Practice Address - City:EXPORT
Practice Address - State:PA
Practice Address - Zip Code:15632-2046
Practice Address - Country:US
Practice Address - Phone:724-733-3762
Practice Address - Fax:724-325-8058
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-14
Last Update Date:2018-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS030346L261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental