Provider Demographics
NPI:1598015257
Name:NICHELINI, JEFFREY (DDS)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:NICHELINI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3419 BROADWAY ST
Mailing Address - Street 2:STE-H1
Mailing Address - City:AMERICAN CANYON
Mailing Address - State:CA
Mailing Address - Zip Code:94503-1261
Mailing Address - Country:US
Mailing Address - Phone:707-651-9244
Mailing Address - Fax:
Practice Address - Street 1:3419 BROADWAY ST
Practice Address - Street 2:STE-H1
Practice Address - City:AMERICAN CANYON
Practice Address - State:CA
Practice Address - Zip Code:94503-1261
Practice Address - Country:US
Practice Address - Phone:707-651-9244
Practice Address - Fax:707-651-9278
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-10
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA604221223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics