Provider Demographics
NPI:1073042271
Name:AINSWORTH, NICOLE RAE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:RAE
Last Name:AINSWORTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6810 MENAUL BLVD NE STE B
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-3725
Mailing Address - Country:US
Mailing Address - Phone:505-872-1100
Mailing Address - Fax:
Practice Address - Street 1:6810 MENAUL BLVD NE STE B
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-3725
Practice Address - Country:US
Practice Address - Phone:505-872-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD46991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice