Healthcare Provider Details

I. General information

NPI: 1699037234
Provider Name (Legal Business Name): NICOLE OBRIEN DS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2012
Last Update Date: 06/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 PLEASANT ST
BROCKTON MA
02301-3052
US

IV. Provider business mailing address

801 PLEASANT ST
BROCKTON MA
02301-3052
US

V. Phone/Fax

Practice location:
  • Phone: 508-586-5977
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: