Provider Demographics
NPI:1265882849
Name:NIMSUWAN, ALISSARA GENA (DMD)
Entity type:Individual
Prefix:DR
First Name:ALISSARA
Middle Name:GENA
Last Name:NIMSUWAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8316 ACCOLADE ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89139-6718
Mailing Address - Country:US
Mailing Address - Phone:702-985-5553
Mailing Address - Fax:
Practice Address - Street 1:7125 N DURANGO DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89149
Practice Address - Country:US
Practice Address - Phone:702-658-2311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-15
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL0190307151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program