Provider Demographics
NPI:1528192713
Name:NISSENBAUM, MATTHEW A (DDS)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:A
Last Name:NISSENBAUM
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 1:221 N WELLWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757-3706
Mailing Address - Country:US
Mailing Address - Phone:631-225-8000
Mailing Address - Fax:631-225-7077
Practice Address - Street 1:221 N WELLWOOD AVE
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:NY
Practice Address - Zip Code:11757-3706
Practice Address - Country:US
Practice Address - Phone:631-225-8000
Practice Address - Fax:631-225-7077
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048062-11223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02771180Medicaid