Provider Demographics
NPI:1669845962
Name:CHILDERS, NICOLE (RDH)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:CHILDERS
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PORTER
Mailing Address - State:ME
Mailing Address - Zip Code:04068-3527
Mailing Address - Country:US
Mailing Address - Phone:207-625-8126
Mailing Address - Fax:
Practice Address - Street 1:70 MAIN ST
Practice Address - Street 2:
Practice Address - City:PORTER
Practice Address - State:ME
Practice Address - Zip Code:04068-3527
Practice Address - Country:US
Practice Address - Phone:207-625-8126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-09
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MERDH4041124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist