Provider Demographics
NPI:1790471704
Name:BOCCHINO, NICHOLAS MARTIN
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:MARTIN
Last Name:BOCCHINO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5410 NEELA LN
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78413-2187
Mailing Address - Country:US
Mailing Address - Phone:816-805-8140
Mailing Address - Fax:
Practice Address - Street 1:1229 SW STATE ROUTE 7
Practice Address - Street 2:
Practice Address - City:BLUE SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64014-3539
Practice Address - Country:US
Practice Address - Phone:816-805-8140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-13
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS620861223G0001X
390200000X
MO20230214731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program