Provider Demographics
NPI:1376608976
Name:NISSEN, NEAL B (DDS)
Entity Type:Individual
Prefix:DR
First Name:NEAL
Middle Name:B
Last Name:NISSEN
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 1:2005 AVENUE L
Mailing Address - Street 2:APT. 1F
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11210-4550
Mailing Address - Country:US
Mailing Address - Phone:718-338-0015
Mailing Address - Fax:
Practice Address - Street 1:2005 AVENUE L
Practice Address - Street 2:APT. 1F
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11210-4550
Practice Address - Country:US
Practice Address - Phone:718-338-0015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY033959-11223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00412579Medicaid