Provider Demographics
NPI:1912090820
Name:NISTA, MARK ANDREW (DMD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ANDREW
Last Name:NISTA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 PFEFFER RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:EXPORT
Mailing Address - State:PA
Mailing Address - Zip Code:15632-1934
Mailing Address - Country:US
Mailing Address - Phone:724-733-3766
Mailing Address - Fax:724-325-8058
Practice Address - Street 1:105 PFEFFER RD
Practice Address - Street 2:SUITE 2
Practice Address - City:EXPORT
Practice Address - State:PA
Practice Address - Zip Code:15632-1934
Practice Address - Country:US
Practice Address - Phone:724-733-3766
Practice Address - Fax:724-325-8058
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS-030346L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice