Provider Demographics
NPI:1356511158
Name:HERMISTON DENTAL GROUP
Entity Type:Organization
Organization Name:HERMISTON DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PABLO
Authorized Official - Middle Name:E
Authorized Official - Last Name:NICACIO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:541-567-4143
Mailing Address - Street 1:540 SW 11TH ST
Mailing Address - Street 2:
Mailing Address - City:HERMISTON
Mailing Address - State:OR
Mailing Address - Zip Code:97838-2108
Mailing Address - Country:US
Mailing Address - Phone:541-567-4143
Mailing Address - Fax:
Practice Address - Street 1:540 SW 11TH ST
Practice Address - Street 2:
Practice Address - City:HERMISTON
Practice Address - State:OR
Practice Address - Zip Code:97838-2108
Practice Address - Country:US
Practice Address - Phone:541-567-4143
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-07
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty