Provider Demographics
NPI:1679964357
Name:BUSSA, NICHOLAS ROBERT
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:ROBERT
Last Name:BUSSA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 ARTHUR AVE SE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414-3412
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11550 SHERIDAN BLVD STE 101
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CO
Practice Address - Zip Code:80020-3312
Practice Address - Country:US
Practice Address - Phone:303-465-0922
Practice Address - Fax:303-691-0889
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-17
Last Update Date:2017-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.00203126122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program