Healthcare Provider Details

I. General information

NPI: 1124736723
Provider Name (Legal Business Name): SAMANTHA ANNE NICOLELLO RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2022
Last Update Date: 11/11/2022
Certification Date: 11/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4044 N LEGACY WOODS AVE
MERIDIAN ID
83646-4480
US

IV. Provider business mailing address

4044 N LEGACY WOODS AVE
MERIDIAN ID
83646-4480
US

V. Phone/Fax

Practice location:
  • Phone: 208-871-0760
  • Fax:
Mailing address:
  • Phone: 208-871-0760
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH-3204
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberDH-3204
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: