Provider Demographics
NPI:1437400173
Name:NICHOLAS, ANN RADOSLAV BUDOVALCEV (DMD)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:RADOSLAV BUDOVALCEV
Last Name:NICHOLAS
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 1:5302 MADISON PIKE
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41051-8652
Mailing Address - Country:US
Mailing Address - Phone:434-249-5151
Mailing Address - Fax:
Practice Address - Street 1:5302 MADISON PIKE
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:KY
Practice Address - Zip Code:41051-8652
Practice Address - Country:US
Practice Address - Phone:434-249-5151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-20
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.0238321223G0001X
KY9693122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice