Provider Demographics
NPI:1134729080
Name:NISSAN, LINORA (DMD)
Entity type:Individual
Prefix:
First Name:LINORA
Middle Name:
Last Name:NISSAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8640 WAUKEGAN RD UNIT 531
Mailing Address - Street 2:
Mailing Address - City:MORTON GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60053-2226
Mailing Address - Country:US
Mailing Address - Phone:847-648-6245
Mailing Address - Fax:
Practice Address - Street 1:3939 W FULLERTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-2243
Practice Address - Country:US
Practice Address - Phone:773-235-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-29
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.032721122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist