Provider Demographics
NPI:1699333880
Name:NISSEN, ANNA ELIZABETH (DDS)
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:ELIZABETH
Last Name:NISSEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 W 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43201-3403
Mailing Address - Country:US
Mailing Address - Phone:419-704-4089
Mailing Address - Fax:
Practice Address - Street 1:4328 OLD WILLIAM PENN HWY
Practice Address - Street 2:
Practice Address - City:MONROEVILLE
Practice Address - State:PA
Practice Address - Zip Code:15146-1496
Practice Address - Country:US
Practice Address - Phone:412-373-7777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-03
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0421771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty