Provider Demographics
NPI:1073606596
Name:DEFABRIQUE, NICOLAS C (DMD)
Entity Type:Individual
Prefix:
First Name:NICOLAS
Middle Name:C
Last Name:DEFABRIQUE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 PGA BLVD.
Mailing Address - Street 2:SUITE 276
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410
Mailing Address - Country:US
Mailing Address - Phone:541-624-5801
Mailing Address - Fax:561-624-7976
Practice Address - Street 1:2401 PGA BLVD.
Practice Address - Street 2:SUITE 276
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33410
Practice Address - Country:US
Practice Address - Phone:541-624-5801
Practice Address - Fax:561-624-7976
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 156421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice