Provider Demographics
NPI:1023241452
Name:NISSON, ROBERT L (DDS, MSD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:L
Last Name:NISSON
Suffix:
Gender:M
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3210 ROYAL DRIVE
Mailing Address - Street 2:
Mailing Address - City:CAMERON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:95682-8506
Mailing Address - Country:US
Mailing Address - Phone:530-677-1769
Mailing Address - Fax:530-677-1680
Practice Address - Street 1:3210 ROYAL DR
Practice Address - Street 2:
Practice Address - City:CAMERON PARK
Practice Address - State:CA
Practice Address - Zip Code:95682-8506
Practice Address - Country:US
Practice Address - Phone:530-677-1769
Practice Address - Fax:530-677-1680
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-02
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA347491223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics