Provider Demographics
NPI:1619974607
Name:NICOLA, DENNIS CRANDALL (DDS)
Entity Type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:CRANDALL
Last Name:NICOLA
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 1:8485 SW CONNEMARA PL
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97008-6934
Mailing Address - Country:US
Mailing Address - Phone:503-641-3612
Mailing Address - Fax:
Practice Address - Street 1:2730 SW MOODY AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97201-5042
Practice Address - Country:US
Practice Address - Phone:503-346-4725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-05
Last Update Date:2014-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD5433122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist