Provider Demographics
NPI:1073963385
Name:DELISLE, NICHOLAS (DMD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:DELISLE
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 1:4800 4TH WAY SW
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-2683
Mailing Address - Country:US
Mailing Address - Phone:702-624-5850
Mailing Address - Fax:
Practice Address - Street 1:74-5214 KKEANALEHU DR
Practice Address - Street 2:
Practice Address - City:KAILUA-KONA
Practice Address - State:HI
Practice Address - Zip Code:96740
Practice Address - Country:US
Practice Address - Phone:808-353-5650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-17
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI30841223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry