Provider Demographics
NPI:1730284217
Name:CAIN, NICHOLAS BERNARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:BERNARD
Last Name:CAIN
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:PO BOX 1430
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-9230
Mailing Address - Country:US
Mailing Address - Phone:219-763-8112
Mailing Address - Fax:219-764-3251
Practice Address - Street 1:3099 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:LAKE STATION
Practice Address - State:IN
Practice Address - Zip Code:46405-2207
Practice Address - Country:US
Practice Address - Phone:219-763-8112
Practice Address - Fax:219-764-3251
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS83181223G0001X
IN12011235A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
INPENDINGMedicaid