Provider Demographics
NPI:1821206061
Name:NUSSBAUM, GIDEON (DDS)
Entity Type:Individual
Prefix:DR
First Name:GIDEON
Middle Name:
Last Name:NUSSBAUM
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 1:607 SW GRADY WAY STE 300
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98055-2977
Mailing Address - Country:US
Mailing Address - Phone:425-255-7633
Mailing Address - Fax:
Practice Address - Street 1:607 SW GRADY WAY STE 300
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-2977
Practice Address - Country:US
Practice Address - Phone:425-255-7633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice