Provider Demographics
NPI:1265921878
Name:NIZZA, MARK ALEXANDER (DMD, MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ALEXANDER
Last Name:NIZZA
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3367 DOUGLAS RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46635-1779
Mailing Address - Country:US
Mailing Address - Phone:574-272-8823
Mailing Address - Fax:574-277-1837
Practice Address - Street 1:3367 DOUGLAS RD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635-1779
Practice Address - Country:US
Practice Address - Phone:574-272-8823
Practice Address - Fax:574-277-1837
Is Sole Proprietor?:No
Enumeration Date:2018-05-09
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.0259471223S0112X
IN12013970A204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery