Provider Demographics
NPI:1558436428
Name:VAN MIEGHEM, NICOLE SERRA (DDS)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:SERRA
Last Name:VAN MIEGHEM
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 1:22807 96TH PL W
Mailing Address - Street 2:
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98020-4544
Mailing Address - Country:US
Mailing Address - Phone:425-775-6507
Mailing Address - Fax:
Practice Address - Street 1:120 W DAYTON ST
Practice Address - Street 2:SUITE C-2
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98020-7217
Practice Address - Country:US
Practice Address - Phone:425-778-7477
Practice Address - Fax:425-778-0406
Is Sole Proprietor?:No
Enumeration Date:2006-11-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00009160122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist