Provider Demographics
NPI:1043621618
Name:POBLETE, NICHOLAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:
Last Name:POBLETE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1316 COFFEE RD
Mailing Address - Street 2:BLDG. C
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-3191
Mailing Address - Country:US
Mailing Address - Phone:209-521-6822
Mailing Address - Fax:209-521-0466
Practice Address - Street 1:1316 COFFEE RD.
Practice Address - Street 2:BLDG. C
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355
Practice Address - Country:US
Practice Address - Phone:209-521-6822
Practice Address - Fax:209-521-6822
Is Sole Proprietor?:No
Enumeration Date:2014-05-16
Last Update Date:2014-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49190122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA260152316Medicaid