Provider Demographics
NPI:1578655734
Name:NIESSEN, LINDA C (DMD)
Entity Type:Individual
Prefix:DR
First Name:LINDA
Middle Name:C
Last Name:NIESSEN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3549 HAYNIE AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75205-1219
Mailing Address - Country:US
Mailing Address - Phone:214-443-0323
Mailing Address - Fax:
Practice Address - Street 1:NORTH TEXAS VA MEDICAL SYSTEM
Practice Address - Street 2:4500 S. LANCASTER AVE
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75216
Practice Address - Country:US
Practice Address - Phone:214-857-1097
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17501122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist