Provider Demographics
NPI:1104386556
Name:ESQUILIN, NICOLE AGNERIS
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:AGNERIS
Last Name:ESQUILIN
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 1:103 E MOUNT ROYAL AVE APT 905
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21202-8114
Mailing Address - Country:US
Mailing Address - Phone:787-379-7983
Mailing Address - Fax:
Practice Address - Street 1:2700 LIGHTHOUSE PT E STE 210
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224-4773
Practice Address - Country:US
Practice Address - Phone:410-675-3300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-21
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD17100122300000X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty