Provider Demographics
NPI:1235904350
Name:CARLS, NIKKI
Entity Type:Individual
Prefix:MRS
First Name:NIKKI
Middle Name:
Last Name:CARLS
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 1:24 SENECA TRL
Mailing Address - Street 2:
Mailing Address - City:PANA
Mailing Address - State:IL
Mailing Address - Zip Code:62557-9719
Mailing Address - Country:US
Mailing Address - Phone:217-820-3434
Mailing Address - Fax:
Practice Address - Street 1:24 SENECA TRL
Practice Address - Street 2:
Practice Address - City:PANA
Practice Address - State:IL
Practice Address - Zip Code:62557-9719
Practice Address - Country:US
Practice Address - Phone:217-820-3434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-20
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL020.007412124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist