MEDICARE: NICHOLAS POTTER

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	DN22789	FL

General Provider Information

NPI Number	:	1932621786
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICHOLAS POTTER

Provider Business Mailing Address
First Line	:	1022 W STATE ROAD 436 STE 1008
Second Line	:
City	:	ALTAMONTE SPRINGS
State	:	FL
Zip	:	32714-2919
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1022 W STATE ROAD 436 STE 1008
Second Line	:
City	:	ALTAMONTE SPRINGS
State	:	FL
Zip	:	32714-2919
Country	:	US
Telephone Number	:	217-540-5100
Fax Number	:

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

Provider Enumeration Date	:	07/13/2017
Last Update Date	:	07/13/2017

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Directions to “ NICHOLAS POTTER ” Practice Location

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