=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417349143
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PETER C NISSLER DDS A DENTAL CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/04/2015
-----------------------------------------------------
Last Update Date | 06/15/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5400 BALBOA BLVD STE 229
-----------------------------------------------------
City | ENCINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91316-5213
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-981-7375
-----------------------------------------------------
Fax | 818-995-8274
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5400 BALBOA BLVD STE 229
-----------------------------------------------------
City | ENCINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91316-5213
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-981-7375
-----------------------------------------------------
Fax | 818-995-8274
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DENTIST
-----------------------------------------------------
Name | DR. PETER CHRISTIAN NISSLER
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 818-981-7375
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 19789
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------