Provider Demographics
NPI:1205157013
Name:NUSSEN, KENNETH HENRY (DDS)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:HENRY
Last Name:NUSSEN
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 1:728 18TH ST
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90402-3020
Mailing Address - Country:US
Mailing Address - Phone:310-395-1888
Mailing Address - Fax:310-395-1200
Practice Address - Street 1:728 18TH ST
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90402-3020
Practice Address - Country:US
Practice Address - Phone:310-395-1888
Practice Address - Fax:310-395-1200
Is Sole Proprietor?:No
Enumeration Date:2010-06-15
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31680122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist