Provider Demographics
NPI:1710208079
Name:GORE, NICOLE C (DMD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:C
Last Name:GORE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 BEARTOOTH DR
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-9004
Mailing Address - Country:US
Mailing Address - Phone:406-638-2626
Mailing Address - Fax:
Practice Address - Street 1:5 BEARTOOTH DR
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-9004
Practice Address - Country:US
Practice Address - Phone:406-638-2626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-21
Last Update Date:2010-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ79411223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health