Healthcare Provider Details

I. General information

NPI: 1376406132
Provider Name (Legal Business Name): NICOLE HOUSTON DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2025
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8035 W MANCHESTER AVE STE A
PLAYA DEL REY CA
90293-7985
US

IV. Provider business mailing address

3500 W MANCHESTER BLVD UNIT 86
INGLEWOOD CA
90305-4086
US

V. Phone/Fax

Practice location:
  • Phone: 310-577-0772
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number112439
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: