Provider Demographics
NPI:1194913673
Name:PHILIP M. NISCO, D.D.S., INC
Entity type:Organization
Organization Name:PHILIP M. NISCO, D.D.S., INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:NISCO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:714-979-1400
Mailing Address - Street 1:17720 NEWHOPE ST
Mailing Address - Street 2:SUITE #227
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708
Mailing Address - Country:US
Mailing Address - Phone:714-979-1400
Mailing Address - Fax:714-979-1403
Practice Address - Street 1:17720 NEWHOPE ST
Practice Address - Street 2:SUITE #227
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708
Practice Address - Country:US
Practice Address - Phone:714-979-1400
Practice Address - Fax:714-979-1403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-09
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0325981223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG92261-01OtherDENTI-CAL