Provider Demographics
NPI:1235679432
Name:BROCCOLI, NICHOLAS (DDS)
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:
Last Name:BROCCOLI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 71930
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23255-1930
Mailing Address - Country:US
Mailing Address - Phone:804-354-1600
Mailing Address - Fax:804-354-1607
Practice Address - Street 1:3811 WESTERRE PKWY
Practice Address - Street 2:STE A
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23233-1329
Practice Address - Country:US
Practice Address - Phone:804-354-1600
Practice Address - Fax:804-354-1607
Is Sole Proprietor?:No
Enumeration Date:2017-03-07
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014173731223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty