MEDICARE: DR. NIKKOLE PATTERSON D.D.S.

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	019.027150	IL
2	1223G0001X	General Practice Dentistry	12010893A	IN

General Provider Information

NPI Number	:	1407002165
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NIKKOLE PATTERSON D.D.S.

Provider Business Mailing Address
First Line	:	823 TRAILWAY DR
Second Line	:
City	:	CHAMPAIGN
State	:	IL
Zip	:	61822-2086
Country	:	US
Telephone Number	:	217-418-2745
Fax Number	:

Provider Business Practice Location Address
First Line	:	3101 VILLAGE OFFICE PL
Second Line	:
City	:	CHAMPAIGN
State	:	IL
Zip	:	61822-7673
Country	:	US
Telephone Number	:	217-352-4646
Fax Number	:

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

Provider Enumeration Date	:	08/13/2008
Last Update Date	:	08/13/2008

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