Provider Demographics
NPI:1467868653
Name:MANIGAULT, NICOLE J (DDS)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:J
Last Name:MANIGAULT
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 1:835 CLAREMONT CENTER DR
Mailing Address - Street 2:
Mailing Address - City:ELKIN
Mailing Address - State:NC
Mailing Address - Zip Code:28621-2488
Mailing Address - Country:US
Mailing Address - Phone:336-835-3337
Mailing Address - Fax:336-835-1241
Practice Address - Street 1:835 CLAREMONT CENTER DR
Practice Address - Street 2:
Practice Address - City:ELKIN
Practice Address - State:NC
Practice Address - Zip Code:28621-2488
Practice Address - Country:US
Practice Address - Phone:336-835-3337
Practice Address - Fax:336-835-1241
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-08
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC97911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice