Provider Demographics
NPI:1790243673
Name:AMELI, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:AMELI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9816 CAMDEN ROSE CT
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89134-5906
Mailing Address - Country:US
Mailing Address - Phone:702-882-9581
Mailing Address - Fax:
Practice Address - Street 1:3505 E HARMON AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-5093
Practice Address - Country:US
Practice Address - Phone:725-237-3940
Practice Address - Fax:702-796-1300
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-09
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV73691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice