Provider Demographics
NPI:1083919625
Name:NICOLE VAN LE, DDS, LLC
Entity Type:Organization
Organization Name:NICOLE VAN LE, DDS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:LE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-442-5411
Mailing Address - Street 1:11623 CANNINGTON CIR
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46037-4398
Mailing Address - Country:US
Mailing Address - Phone:317-442-5411
Mailing Address - Fax:
Practice Address - Street 1:9105 E 56TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46216-2229
Practice Address - Country:US
Practice Address - Phone:317-442-5411
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-12
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010056122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty