Provider Demographics
NPI:1083063754
Name:GOLBA, NICHOLAS T (DDS)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:T
Last Name:GOLBA
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 1:301 EXPLORER ST
Mailing Address - Street 2:
Mailing Address - City:GWINN
Mailing Address - State:MI
Mailing Address - Zip Code:49841-2813
Mailing Address - Country:US
Mailing Address - Phone:906-483-1177
Mailing Address - Fax:906-372-3230
Practice Address - Street 1:56720 CALUMET AVE
Practice Address - Street 2:
Practice Address - City:CALUMET
Practice Address - State:MI
Practice Address - Zip Code:49913-1967
Practice Address - Country:US
Practice Address - Phone:906-483-1177
Practice Address - Fax:906-372-3230
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-03
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010218971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice