Provider Demographics
NPI:1992853055
Name:NUSSBAUM, JACQUELINE I (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:I
Last Name:NUSSBAUM
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 MAGNOLIA LN
Mailing Address - Street 2:
Mailing Address - City:JERICHO
Mailing Address - State:NY
Mailing Address - Zip Code:11753-2228
Mailing Address - Country:US
Mailing Address - Phone:516-938-1747
Mailing Address - Fax:
Practice Address - Street 1:77 QUAKER RIDGE RD
Practice Address - Street 2:SUITE 206
Practice Address - City:NEW ROCHELLE
Practice Address - State:NY
Practice Address - Zip Code:10804-2808
Practice Address - Country:US
Practice Address - Phone:917-636-4118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0464691223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics