MEDICARE: DR. NICOLE ROSE DUBOIS DMD

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	10260	SC

General Provider Information

NPI Number	:	1194457085
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NICOLE ROSE DUBOIS DMD

Provider Business Mailing Address
First Line	:	2038 LAKE MURRAY BLVD APT 15208
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29212-0866
Country	:	US
Telephone Number	:	757-243-3293
Fax Number	:

Provider Business Practice Location Address
First Line	:	5443 PLATT SPRINGS RD STE F
Second Line	:
City	:	LEXINGTON
State	:	SC
Zip	:	29073-6203
Country	:	US
Telephone Number	:	803-470-5067
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/29/2022
Last Update Date	:	06/29/2022

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