Provider Demographics
NPI:1083135933
Name:GUIRGUIS, NICOLE (DDS)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:GUIRGUIS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4139 VIA MARINA APT 810
Mailing Address - Street 2:
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-5365
Mailing Address - Country:US
Mailing Address - Phone:631-455-9521
Mailing Address - Fax:
Practice Address - Street 1:8301 IMPERIAL HWY
Practice Address - Street 2:
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90242-3830
Practice Address - Country:US
Practice Address - Phone:562-273-3207
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-30
Last Update Date:2019-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103780122300000X
TN10570122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist