Healthcare Provider Details

I. General information

NPI: 1104386556
Provider Name (Legal Business Name): NICOLE AGNERIS ESQUILIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2019
Last Update Date: 05/10/2021
Certification Date: 05/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 LIGHTHOUSE PT E STE 210
BALTIMORE MD
21224-4773
US

IV. Provider business mailing address

103 E MOUNT ROYAL AVE APT 905
BALTIMORE MD
21202-8114
US

V. Phone/Fax

Practice location:
  • Phone: 410-675-3300
  • Fax:
Mailing address:
  • Phone: 787-379-7983
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number17100
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: