Provider Demographics
NPI:1962421388
Name:NUSSBAUM, GARY BRUCE (DMD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:BRUCE
Last Name:NUSSBAUM
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 1:1940 BRAEBURN DR
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:VA
Mailing Address - Zip Code:24153-7383
Mailing Address - Country:US
Mailing Address - Phone:540-989-5257
Mailing Address - Fax:
Practice Address - Street 1:1940 BRAEBURN DR
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-7383
Practice Address - Country:US
Practice Address - Phone:540-989-5257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010052231223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAT21402Medicare UPIN