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General NPI Number Information
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NPI Number | 1578752044
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Entity Type | Organization
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Legal Business Name | DR PAUL RUSSELL A NICOTRA DDS LTD
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Dates
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Enumeration Date | 10/19/2007
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Last Update Date | 10/19/2007
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Provider Practice Location Address
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Address Line | 135 W JOHNSON ST STE #3
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City | PALATINE
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State | IL
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Zip | 60067
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Country | US
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Telephone | 847-358-4700
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Fax | 847-358-8625
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Provider Business Mailing Address
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Address Line | 135 W JOHNSON ST STE #3
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City | PALATINE
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State | IL
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Zip | 60067
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Country | US
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Telephone | 847-358-4700
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Fax | 847-358-8625
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Authorized Official
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Title or Position | PRES
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Name | DR. PAUL R A NICOTRA SR.
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Credential | DDS
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Telephone | 847-358-4700
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 01913082
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License Number State | IL
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