Provider Demographics
NPI:1821425166
Name:NISENBOYM, DAVID (DDS)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:NISENBOYM
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 1:130 PETTICOAT LN
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94596-5017
Mailing Address - Country:US
Mailing Address - Phone:916-704-0974
Mailing Address - Fax:
Practice Address - Street 1:130 PETTICOAT LN
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94596-5017
Practice Address - Country:US
Practice Address - Phone:916-704-0974
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-01
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63382122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist