Provider Demographics
NPI:1003914110
Name:MCNICHOLL, IRIS CORINA (DDS)
Entity Type:Individual
Prefix:DR
First Name:IRIS
Middle Name:CORINA
Last Name:MCNICHOLL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1481 WEST 10TH STREET
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202
Mailing Address - Country:US
Mailing Address - Phone:317-988-2733
Mailing Address - Fax:317-988-5377
Practice Address - Street 1:1481 WEST 10TH STREET
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202
Practice Address - Country:US
Practice Address - Phone:317-988-2733
Practice Address - Fax:317-988-5377
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2017-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009732122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200169270AMedicaid