Provider Demographics
NPI:1497370720
Name:BUNDY, NICOLE CHRISTINE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:CHRISTINE
Last Name:BUNDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6451 N ELMS RD
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:MI
Mailing Address - Zip Code:48433-9039
Mailing Address - Country:US
Mailing Address - Phone:810-247-1314
Mailing Address - Fax:
Practice Address - Street 1:611 N SHIAWASSEE ST
Practice Address - Street 2:
Practice Address - City:CORUNNA
Practice Address - State:MI
Practice Address - Zip Code:48817-1039
Practice Address - Country:US
Practice Address - Phone:989-743-4851
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-12
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901600483122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist