Provider Demographics
NPI:1255856043
Name:NISSEN, TINA MARIE (RDH)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:NISSEN
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1141 W WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-2628
Mailing Address - Country:US
Mailing Address - Phone:920-988-7971
Mailing Address - Fax:
Practice Address - Street 1:856 ARMOUR RD STE B
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-3976
Practice Address - Country:US
Practice Address - Phone:262-569-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-14
Last Update Date:2017-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11404124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist