MEDICARE: NICOLE L. CHRISTY DDS PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1033274071
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NICOLE L. CHRISTY DDS PC

Provider Business Mailing Address
First Line	:	909 N WASHINGTON ST
Second Line	:
City	:	BOURBON
State	:	IN
Zip	:	46504-1447
Country	:	US
Telephone Number	:	574-342-4385
Fax Number	:	574-342-0461

Provider Business Practice Location Address
First Line	:	909 N WASHINGTON ST
Second Line	:
City	:	BOURBON
State	:	IN
Zip	:	46504-1447
Country	:	US
Telephone Number	:	574-342-4385
Fax Number	:	574-342-0461

Authorized Official
Title or Position	:	OWNER
Name	:	DR. NICOLE LYNN CHRISTY
Credential	:	D.D.S.
Telephone Number	:	574-342-4385

Provider Enumeration Date	:	12/27/2006
Last Update Date	:	07/15/2008

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