Provider Demographics
NPI:1245396274
Name:NIETO, JORGE E (RDH, DMD)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:E
Last Name:NIETO
Suffix:
Gender:M
Credentials:RDH, DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:176 W CHEW AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19120-2460
Mailing Address - Country:US
Mailing Address - Phone:215-924-4677
Mailing Address - Fax:
Practice Address - Street 1:176 W CHEW AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19120-2460
Practice Address - Country:US
Practice Address - Phone:215-924-4677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS-028100-L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice