Provider Demographics
NPI:1114628633
Name:DI NARDI, JACQUELINE NICOLE NICOLE (RDH)
Entity Type:Individual
Prefix:
First Name:JACQUELINE NICOLE
Middle Name:NICOLE
Last Name:DI NARDI
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7535 VALLEY AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-3130
Mailing Address - Country:US
Mailing Address - Phone:215-510-1540
Mailing Address - Fax:646-834-0887
Practice Address - Street 1:7535 VALLEY AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19128-3130
Practice Address - Country:US
Practice Address - Phone:215-510-1540
Practice Address - Fax:646-834-0887
Is Sole Proprietor?:No
Enumeration Date:2023-03-13
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADH013269L124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist