Provider Demographics
NPI:1902897184
Name:NISSENBAUM, MARK (DMD MDC FCDSA OMFS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:NISSENBAUM
Suffix:
Gender:M
Credentials:DMD MDC FCDSA OMFS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:200 BOYLSTON ST
Mailing Address - Street 2:SUITE 305
Mailing Address - City:CHESTNUT HILL
Mailing Address - State:MA
Mailing Address - Zip Code:02467-2012
Mailing Address - Country:US
Mailing Address - Phone:617-731-8888
Mailing Address - Fax:617-731-3107
Practice Address - Street 1:200 BOYLSTON ST
Practice Address - Street 2:SUITE 305
Practice Address - City:CHESTNUT HILL
Practice Address - State:MA
Practice Address - Zip Code:02467-2012
Practice Address - Country:US
Practice Address - Phone:617-731-8888
Practice Address - Fax:617-731-3107
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA8460204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery