Provider Demographics
NPI:1205211398
Name:EPIFANIA V NICOLAS DDS INC
Entity Type:Organization
Organization Name:EPIFANIA V NICOLAS DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EPIFANIA
Authorized Official - Middle Name:
Authorized Official - Last Name:NICOLAS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:760-922-2300
Mailing Address - Street 1:301 E HOBSONWAY
Mailing Address - Street 2:
Mailing Address - City:BLYTHE
Mailing Address - State:CA
Mailing Address - Zip Code:92225-1732
Mailing Address - Country:US
Mailing Address - Phone:760-922-2300
Mailing Address - Fax:
Practice Address - Street 1:301 E HOBSONWAY
Practice Address - Street 2:
Practice Address - City:BLYTHE
Practice Address - State:CA
Practice Address - Zip Code:92225-1732
Practice Address - Country:US
Practice Address - Phone:760-922-2300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-30
Last Update Date:2015-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40290122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty