MEDICARE: DR. NICOLE A IIDA DDS

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	122300000X	Dentist	D12223	OR

General Provider Information

NPI Number	:	1386533297
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NICOLE A IIDA DDS

Provider Business Mailing Address
First Line	:	217 E MCANDREWS RD APT 219
Second Line	:
City	:	MEDFORD
State	:	OR
Zip	:	97501-2058
Country	:	US
Telephone Number	:	251-401-8958
Fax Number	:

Provider Business Practice Location Address
First Line	:	1759 N RIVERSIDE AVE
Second Line	:
City	:	MEDFORD
State	:	OR
Zip	:	97501-4628
Country	:	US
Telephone Number	:	541-227-5290
Fax Number	:

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

Provider Enumeration Date	:	07/03/2025
Last Update Date	:	07/03/2025

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