Provider Demographics
NPI:1477715514
Name:AMUNDSON, NICOLE R (DDS)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:R
Last Name:AMUNDSON
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 1:11475 ROBINSON DR NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433
Mailing Address - Country:US
Mailing Address - Phone:763-587-9100
Mailing Address - Fax:763-587-9101
Practice Address - Street 1:11475 ROBINSON DR NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433
Practice Address - Country:US
Practice Address - Phone:763-587-9100
Practice Address - Fax:763-587-9101
Is Sole Proprietor?:No
Enumeration Date:2008-06-30
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN125281223G0001X
MND12528122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice