Provider Demographics
NPI:1578287991
Name:BURLINGAME, NICOLE L
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:L
Last Name:BURLINGAME
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 1:111 W JACKSON ST FL 3
Mailing Address - Street 2:
Mailing Address - City:WISCONSIN RAPIDS
Mailing Address - State:WI
Mailing Address - Zip Code:54495-2702
Mailing Address - Country:US
Mailing Address - Phone:715-421-8937
Mailing Address - Fax:
Practice Address - Street 1:111 W JACKSON ST FL 3
Practice Address - Street 2:
Practice Address - City:WISCONSIN RAPIDS
Practice Address - State:WI
Practice Address - Zip Code:54495-2702
Practice Address - Country:US
Practice Address - Phone:715-421-8937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-29
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1004065-16124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist