Provider Demographics
NPI:1104370972
Name:MAHANIAN, NICOLE
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:
Last Name:MAHANIAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2005 EVERGREEN ST
Mailing Address - Street 2:SUITE 1550
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95815-3892
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2005 EVERGREEN ST
Practice Address - Street 2:SUITE 1550
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95815-3892
Practice Address - Country:US
Practice Address - Phone:310-486-4772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-10
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA100589122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist