Provider Demographics
NPI:1548608516
Name:SHVARTSUR, NIKOLE DESIREE YOUNG (DDS)
Entity Type:Individual
Prefix:DR
First Name:NIKOLE
Middle Name:DESIREE YOUNG
Last Name:SHVARTSUR
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 1:710 NW JUNIPER ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-2717
Mailing Address - Country:US
Mailing Address - Phone:425-392-4600
Mailing Address - Fax:
Practice Address - Street 1:710 NW JUNIPER ST
Practice Address - Street 2:SUITE 101
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-2717
Practice Address - Country:US
Practice Address - Phone:425-392-4600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-11
Last Update Date:2013-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADENT.DE.60364933122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist