Provider Demographics
NPI:1700980950
Name:NISSENBAUM, EDWARD (DDS)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:NISSENBAUM
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 1:6 XAVIER DRIVE
Mailing Address - Street 2:SUITE 310
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10704
Mailing Address - Country:US
Mailing Address - Phone:914-423-1111
Mailing Address - Fax:914-423-0333
Practice Address - Street 1:6 XAVIER DRIVE
Practice Address - Street 2:SUITE 310
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10704
Practice Address - Country:US
Practice Address - Phone:914-423-1111
Practice Address - Fax:914-423-0333
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029069122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist