Provider Demographics
NPI:1093846602
Name:BRAND, NICKELICE (DDS)
Entity Type:Individual
Prefix:DR
First Name:NICKELICE
Middle Name:
Last Name:BRAND
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 1:1325 S INTERNATIONAL PKWY
Mailing Address - Street 2:SUITE 1201
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-1406
Mailing Address - Country:US
Mailing Address - Phone:407-235-5071
Mailing Address - Fax:
Practice Address - Street 1:707 PENNSYLVANIA AVE
Practice Address - Street 2:SUITE 1200
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32701-6471
Practice Address - Country:US
Practice Address - Phone:407-235-5071
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL00122761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice