Provider Demographics
NPI:1902672066
Name:NITIBHON, ORISSA (DMD)
Entity type:Individual
Prefix:DR
First Name:ORISSA
Middle Name:
Last Name:NITIBHON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1260 MILTON AVE
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53545-1889
Mailing Address - Country:US
Mailing Address - Phone:608-757-0057
Mailing Address - Fax:
Practice Address - Street 1:460 CRESCENT ST
Practice Address - Street 2:
Practice Address - City:MENOMONIE
Practice Address - State:WI
Practice Address - Zip Code:54751-1827
Practice Address - Country:US
Practice Address - Phone:715-972-9975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-29
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6001518-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice