Provider Demographics
NPI:1790001436
Name:REDDOUT, NICOLE MARIE (DMD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:MARIE
Last Name:REDDOUT
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 1:112 MERIDIAN PL
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23435-3787
Mailing Address - Country:US
Mailing Address - Phone:702-374-8217
Mailing Address - Fax:
Practice Address - Street 1:1647 ADMIRAL TAUSSIG BLVD
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23511-2803
Practice Address - Country:US
Practice Address - Phone:757-953-8605
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-19
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04380003681223S0112X
VA0401415421122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist