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General NPI Number Information
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NPI Number | 1902897184
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Entity Type | Individual
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Provider Name | MARK NISSENBAUM DMD MDC FCDSA OMFS
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Gender | Male
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Dates
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Enumeration Date | 11/04/2005
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Last Update Date | 02/27/2014
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Provider Practice Location Address
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Address Line | 200 BOYLSTON ST SUITE 305
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City | CHESTNUT HILL
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State | MA
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Zip | 02467-2012
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Country | US
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Telephone | 617-731-8888
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Fax | 617-731-3107
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Provider Business Mailing Address
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Address Line | 200 BOYLSTON ST SUITE 305
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City | CHESTNUT HILL
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State | MA
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Zip | 02467-2012
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Country | US
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Telephone | 617-731-8888
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Fax | 617-731-3107
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 204E00000X
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Taxonomy Name | Oral & Maxillofacial Surgery (D.M.D.)
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License Number | 8460
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License Number State | MA
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