Provider Demographics
NPI:1316379126
Name:YATES, NICOLE BRIANNE (DMD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:BRIANNE
Last Name:YATES
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CENTRALIZED CRED. AND PRIV DIR. 554 KEILY STREET
Mailing Address - Street 2:BUREAU OF MEDICINE AND SURGERY
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32212
Mailing Address - Country:US
Mailing Address - Phone:757-953-7011
Mailing Address - Fax:
Practice Address - Street 1:CENTRALIZED CRED. AND PRIV DIR. 554 KEILY STREET
Practice Address - Street 2:BUREAU OF MEDICINE AND SURGERY
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32212
Practice Address - Country:US
Practice Address - Phone:757-953-7011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-02
Last Update Date:2013-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN014620122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist