Basic Information
| Provider Information | |||||||||
| NPI: | 1811619299 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NISNISAN | ||||||||
| FirstName: | MARY JOCELYN ELYSE | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2138 THISTLEROCK LN | ||||||||
| Address2: | |||||||||
| City: | SUGAR LAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774798829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8326513240 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3415 FM 762 RD STE 150 | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774695507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8324314316 | ||||||||
| FaxNumber: | 8324760600 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2022 | ||||||||
| LastUpdateDate: | 09/13/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 38984 | TX | Y | Dental Providers | Dentist | General Practice |
No ID Information.