Healthcare Provider Details

I. General information

NPI: 1366624629
Provider Name (Legal Business Name): PAMELA A NICOARA DDS MSD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2007
Last Update Date: 11/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3125 COLBY AVE SUITE H
EVERETT WA
98201-4032
US

IV. Provider business mailing address

2012 GRAND AVE
EVERETT WA
98201-2212
US

V. Phone/Fax

Practice location:
  • Phone: 425-374-5380
  • Fax: 425-374-5382
Mailing address:
  • Phone: 206-218-7352
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number10770
License Number StateWA

VIII. Authorized Official

Name: DR. PAMELA ADRIENNE NICOARA
Title or Position: OWNER/PERIODONTIST
Credential: DDS MSD PLLC
Phone: 425-374-5380