Provider Demographics
NPI:1235404716
Name:NUSSENBAUM, NATHAN (DDS)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:NUSSENBAUM
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 1:130 MYERS DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76108-2036
Mailing Address - Country:US
Mailing Address - Phone:561-909-8232
Mailing Address - Fax:
Practice Address - Street 1:8008 CAMP BOWIE BLVD W
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76116
Practice Address - Country:US
Practice Address - Phone:817-335-5555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-15
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX237451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice