Provider Demographics
NPI:1386777183
Name:NISSEN, LARRY WAYNE (DDS)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:WAYNE
Last Name:NISSEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:280 N SYKES CREEK PKWY STE C
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32953-3491
Mailing Address - Country:US
Mailing Address - Phone:321-452-5500
Mailing Address - Fax:321-452-2125
Practice Address - Street 1:280 N SYKES CREEK PKWY
Practice Address - Street 2:SUITE C
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-3491
Practice Address - Country:US
Practice Address - Phone:321-452-5500
Practice Address - Fax:321-452-2125
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL73151223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery