Provider Demographics
NPI:1376708933
Name:YOUNGERS, NICOLE (DDS)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:YOUNGERS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3896 CAMEO PL NE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55906-5459
Mailing Address - Country:US
Mailing Address - Phone:515-954-9206
Mailing Address - Fax:
Practice Address - Street 1:1705 BROADWAY AVE S
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55904
Practice Address - Country:US
Practice Address - Phone:507-288-0120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-23
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD9120122300000X
IA08796390200000X
MND140511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR023504Medicaid