Provider Demographics
NPI:1114680337
Name:NICOSON, REBECCA ANN (RDH)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:ANN
Last Name:NICOSON
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 1:6365 LAMAR TRL
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:MT
Mailing Address - Zip Code:59833-5947
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6365 LAMAR TRL
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:MT
Practice Address - Zip Code:59833-5947
Practice Address - Country:US
Practice Address - Phone:406-544-9662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-14
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1026124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty