Provider Demographics
NPI:1467772244
Name:GANDOLA, NICOLAS
Entity Type:Individual
Prefix:
First Name:NICOLAS
Middle Name:
Last Name:GANDOLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2650 NORTH AVE UNIT 101
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501-6403
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2650 NORTH AVE UNIT 101
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-6403
Practice Address - Country:US
Practice Address - Phone:970-255-1222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-03
Last Update Date:2010-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO101751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice