Provider Demographics
NPI:1003876079
Name:NUSSBAUM, BURTON L (DDS)
Entity Type:Individual
Prefix:DR
First Name:BURTON
Middle Name:L
Last Name:NUSSBAUM
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 1:1 S FORGE LN
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08002-2588
Mailing Address - Country:US
Mailing Address - Phone:856-667-2593
Mailing Address - Fax:856-482-7825
Practice Address - Street 1:1 S FORGE LN
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08002-2550
Practice Address - Country:US
Practice Address - Phone:856-667-2123
Practice Address - Fax:856-482-7825
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ118291223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2455706Medicaid
NJU02546Medicare UPIN