MEDICARE: DR. SCOTT JONATHAN NICOLETTE 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	1223G0001X	General Practice Dentistry	22064	OH

General Provider Information

NPI Number	:	1629056775
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SCOTT JONATHAN NICOLETTE DDS

Provider Business Mailing Address
First Line	:	5109 W BROAD ST
Second Line	:	202
City	:	COLUMBUS
State	:	OH
Zip	:	43228-1648
Country	:	US
Telephone Number	:	614-878-2273
Fax Number	:	614-878-0958

Provider Business Practice Location Address
First Line	:	5109 W BROAD ST
Second Line	:	202
City	:	COLUMBUS
State	:	OH
Zip	:	43228-1648
Country	:	US
Telephone Number	:	614-878-2273
Fax Number	:	614-878-0958

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

Provider Enumeration Date	:	01/07/2006
Last Update Date	:	07/08/2007

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