Healthcare Provider Details

I. General information

NPI: 1992157846
Provider Name (Legal Business Name): NICOLE DIANA DEL CARPIO D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/04/2016
Last Update Date: 07/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4015 HURST DR
WATERLOO IA
50701-9035
US

IV. Provider business mailing address

4312 PEARL AVE NW
CEDAR RAPIDS IA
52405-5405
US

V. Phone/Fax

Practice location:
  • Phone: 319-235-6287
  • Fax:
Mailing address:
  • Phone: 515-290-1718
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDDS-09320
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: