Provider Demographics
NPI:1124360961
Name:NISHISAKI, KAZUKO (DDS)
Entity Type:Individual
Prefix:DR
First Name:KAZUKO
Middle Name:
Last Name:NISHISAKI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 N ESSEX AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:NARBERTH
Mailing Address - State:PA
Mailing Address - Zip Code:19072-2233
Mailing Address - Country:US
Mailing Address - Phone:610-668-7750
Mailing Address - Fax:610-668-7751
Practice Address - Street 1:106 N ESSEX AVE
Practice Address - Street 2:SUITE C
Practice Address - City:NARBERTH
Practice Address - State:PA
Practice Address - Zip Code:19072-2233
Practice Address - Country:US
Practice Address - Phone:610-668-7750
Practice Address - Fax:610-668-7751
Is Sole Proprietor?:No
Enumeration Date:2013-03-19
Last Update Date:2016-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS037565122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAL0016789780001Medicaid