Provider Demographics
NPI:1114376126
Name:EPIFANIA V NICOLAS
Entity Type:Organization
Organization Name:EPIFANIA V NICOLAS
Other - Org Name:NICOLAS DENTAL CORPORATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:EPIFANIA
Authorized Official - Middle Name:VIOLA
Authorized Official - Last Name:NICOLAS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:661-845-2246
Mailing Address - Street 1:414 TENNESSEE ST
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-8163
Mailing Address - Country:US
Mailing Address - Phone:909-798-4000
Mailing Address - Fax:909-798-5020
Practice Address - Street 1:414 TENNEESE ST
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-8126
Practice Address - Country:US
Practice Address - Phone:909-798-4000
Practice Address - Fax:909-798-5020
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NICOLAS DENTAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-06-09
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40290122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty