Provider Demographics
NPI:1609280395
Name:OPHASO, NISSA (DMD)
Entity Type:Individual
Prefix:
First Name:NISSA
Middle Name:
Last Name:OPHASO
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 1:1701 JOE HARVEY BLVD
Mailing Address - Street 2:STE B
Mailing Address - City:HOBBS
Mailing Address - State:NM
Mailing Address - Zip Code:88240
Mailing Address - Country:US
Mailing Address - Phone:847-701-1455
Mailing Address - Fax:
Practice Address - Street 1:2050 E ALGONQUIN RD
Practice Address - Street 2:STE 610
Practice Address - City:SCHAUMBURG
Practice Address - State:IL
Practice Address - Zip Code:60173-4144
Practice Address - Country:US
Practice Address - Phone:847-701-1455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-20
Last Update Date:2014-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD41091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice