Healthcare Provider Details

I. General information

NPI: 1508500984
Provider Name (Legal Business Name): NICOLE YOUD DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2022
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1814 SAINT ANDREWS BLVD
PANAMA CITY FL
32405-2838
US

IV. Provider business mailing address

1814 SAINT ANDREWS BLVD
PANAMA CITY FL
32405-2838
US

V. Phone/Fax

Practice location:
  • Phone: 850-215-0798
  • Fax:
Mailing address:
  • Phone: 850-215-0798
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN31643
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number0442000451
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN124049
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: