Provider Demographics
NPI:1538133665
Name:NISSMAN, CHARLES BERYL (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:BERYL
Last Name:NISSMAN
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 1:137 W STREET RD
Mailing Address - Street 2:
Mailing Address - City:FEASTERVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19053-4168
Mailing Address - Country:US
Mailing Address - Phone:215-322-7810
Mailing Address - Fax:215-322-7832
Practice Address - Street 1:137 W STREET RD
Practice Address - Street 2:
Practice Address - City:FEASTERVILLE
Practice Address - State:PA
Practice Address - Zip Code:19053-4168
Practice Address - Country:US
Practice Address - Phone:215-322-7810
Practice Address - Fax:215-322-7832
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS017304L174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA4437OtherAETNA
PA160558OtherBLUE SHIELD
PA0023182000OtherKEYSTONE
PA160558OtherBLUE SHIELD
NI160558Medicare ID - Type Unspecified