Provider Demographics
NPI:1710765532
Name:BREWSTER, NICOLE LYNN (RDH BSDH MSADT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LYNN
Last Name:BREWSTER
Suffix:
Gender:F
Credentials:RDH BSDH MSADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10620 SOUTHERN HIGHLANDS PKWY # 110-361
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89141-4371
Mailing Address - Country:US
Mailing Address - Phone:702-205-6273
Mailing Address - Fax:
Practice Address - Street 1:2430 E HARMON AVE STE 1
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-5338
Practice Address - Country:US
Practice Address - Phone:702-796-0095
Practice Address - Fax:702-761-4551
Is Sole Proprietor?:No
Enumeration Date:2023-09-21
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNDT120125J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes125J00000XDental ProvidersDental Therapist