=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548961303
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NICOLE DEL CARPIO DDS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/16/2023
-----------------------------------------------------
Last Update Date | 03/16/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7255 S 76TH ST
-----------------------------------------------------
City | FRANKLIN
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53132-9041
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-425-0500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5880 S RACINE AVE
-----------------------------------------------------
City | NEW BERLIN
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53146-4927
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-290-1718
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | NICOLE DEL CARPIO TENGAN
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 515-290-1718
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------