=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972881555
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICOLE MICHELLE TROMBETTA DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2011
-----------------------------------------------------
Last Update Date | 12/27/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13808 N. SANDARIO RD
-----------------------------------------------------
City | MARANA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85653
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-616-0921
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 80 W BOXELDER PL
-----------------------------------------------------
City | ORO VALLEY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85755-8914
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-739-8888
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | D008285
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------