Healthcare Provider Details

I. General information

NPI: 1770818585
Provider Name (Legal Business Name): NICOLE RENAE NIELSEN RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2009
Last Update Date: 10/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 NORTH AVE
GRAND JUNCTION CO
81501-6428
US

IV. Provider business mailing address

553 GARFIELD DR APT 3
GRAND JUNCTION CO
81504-5393
US

V. Phone/Fax

Practice location:
  • Phone: 970-263-5062
  • Fax:
Mailing address:
  • Phone: 970-629-2891
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number905647
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number7085689-9920
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: