MEDICARE: GLENDA NUCKOLS, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1306171947
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GLENDA NUCKOLS, PC

Provider Business Mailing Address
First Line	:	181 FM 3237
Second Line	:
City	:	WIMBERLEY
State	:	TX
Zip	:	78676-5324
Country	:	US
Telephone Number	:	512-847-8934
Fax Number	:	512-847-6262

Provider Business Practice Location Address
First Line	:	181 FM 3237
Second Line	:
City	:	WIMBERLEY
State	:	TX
Zip	:	78676-5324
Country	:	US
Telephone Number	:	512-847-8934
Fax Number	:	512-847-6262

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. GLENDA NUCKOLS
Credential	:	DDS
Telephone Number	:	512-847-8934

Provider Enumeration Date	:	10/15/2009
Last Update Date	:	11/17/2009

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