=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114049160
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANNE A. NICHOLAS D.D.S.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 73929 LARREA ST SUITE 2
-----------------------------------------------------
City | PALM DESERT
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92260-4305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-340-1030
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 75347 MONTECITO DR
-----------------------------------------------------
City | INDIAN WELLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92210-8358
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-340-1030
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | 37966
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------