Provider Demographics
NPI:1922121045
Name:NISS, PAVEL
Entity Type:Individual
Prefix:
First Name:PAVEL
Middle Name:
Last Name:NISS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9050 SEPULVEDA BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91343-4308
Mailing Address - Country:US
Mailing Address - Phone:818-672-8800
Mailing Address - Fax:
Practice Address - Street 1:9050 SEPULVEDA BLVD
Practice Address - Street 2:
Practice Address - City:NORTH HILLS
Practice Address - State:CA
Practice Address - Zip Code:91343-4308
Practice Address - Country:US
Practice Address - Phone:818-672-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45513122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist