MEDICARE: DR. GIDEON NUSSBAUM DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	6136	WA

General Provider Information

NPI Number	:	1821206061
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GIDEON NUSSBAUM DDS

Provider Business Mailing Address
First Line	:	607 SW GRADY WAY STE 300
Second Line	:
City	:	RENTON
State	:	WA
Zip	:	98055-2977
Country	:	US
Telephone Number	:	425-255-7633
Fax Number	:

Provider Business Practice Location Address
First Line	:	607 SW GRADY WAY STE 300
Second Line	:
City	:	RENTON
State	:	WA
Zip	:	98055-2977
Country	:	US
Telephone Number	:	425-255-7633
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/20/2007
Last Update Date	:	07/08/2007

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