Provider Demographics
NPI:1174295091
Name:SADUSK, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:SADUSK
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 1:191 AZURE MIST WAY
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32124-3704
Mailing Address - Country:US
Mailing Address - Phone:386-383-4848
Mailing Address - Fax:
Practice Address - Street 1:1500 BEVILLE RD STE 403
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-5644
Practice Address - Country:US
Practice Address - Phone:386-253-6634
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-29
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDH17651124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist