MEDICARE: DR. NINA WALLICK 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	122300000X	Dentist	DN31036	FL
2	122300000X	Dentist	DS044144	PA

General Provider Information

NPI Number	:	1861177834
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NINA WALLICK DMD

Provider Business Mailing Address
First Line	:	3310 W MALLORY BLVD
Second Line	:
City	:	JUPITER
State	:	FL
Zip	:	33458-8772
Country	:	US
Telephone Number	:	561-818-2003
Fax Number	:

Provider Business Practice Location Address
First Line	:	812 SW FEDERAL HWY
Second Line	:
City	:	STUART
State	:	FL
Zip	:	34994-2939
Country	:	US
Telephone Number	:	772-287-1671
Fax Number	:

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

Provider Enumeration Date	:	06/19/2023
Last Update Date	:	01/12/2026

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