Provider Demographics
NPI:1417349143
Name:PETER C NISSLER DDS A DENTAL CORP
Entity Type:Organization
Organization Name:PETER C NISSLER DDS A DENTAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:CHRISTIAN
Authorized Official - Last Name:NISSLER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:818-981-7375
Mailing Address - Street 1:5400 BALBOA BLVD STE 229
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-5213
Mailing Address - Country:US
Mailing Address - Phone:818-981-7375
Mailing Address - Fax:818-995-8274
Practice Address - Street 1:5400 BALBOA BLVD STE 229
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-5213
Practice Address - Country:US
Practice Address - Phone:818-981-7375
Practice Address - Fax:818-995-8274
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-04
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19789261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center