Healthcare Provider Details

I. General information

NPI: 1003319260
Provider Name (Legal Business Name): NISTA FAMILY DENTAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2018
Last Update Date: 03/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 PFEFFER RD STE 2
EXPORT PA
15632-2046
US

IV. Provider business mailing address

105 PFEFFER RD STE 2
EXPORT PA
15632-2046
US

V. Phone/Fax

Practice location:
  • Phone: 724-733-3762
  • Fax: 724-325-8058
Mailing address:
  • Phone: 724-733-3762
  • Fax: 724-325-8058

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberDS030346L
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. MARK A NISTA
Title or Position: OWNER
Credential: DMD
Phone: 724-733-3762