Healthcare Provider Details

I. General information

NPI: 1215046008
Provider Name (Legal Business Name): RICHARD JAMES NISSEN DDS, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 04/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 THE BOULEVARD-ST. LOUIS
SAINT LOUIS MO
63117
US

IV. Provider business mailing address

31 THE BOULEVARD-ST. LOUIS
SAINT LOUIS MO
63117
US

V. Phone/Fax

Practice location:
  • Phone: 314-727-6162
  • Fax: 314-727-7259
Mailing address:
  • Phone: 314-727-6162
  • Fax: 314-727-7259

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number14094
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number014094
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: