Provider Demographics
NPI:1841595824
Name:ABRAHAM, NICOLE AJALAT (DDS)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:AJALAT
Last Name:ABRAHAM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5407 COLFAX AVE APT 207
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91601-5206
Mailing Address - Country:US
Mailing Address - Phone:626-253-6862
Mailing Address - Fax:
Practice Address - Street 1:2028 LAKE AVE
Practice Address - Street 2:
Practice Address - City:ALTADENA
Practice Address - State:CA
Practice Address - Zip Code:91001-2450
Practice Address - Country:US
Practice Address - Phone:626-797-7551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-21
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59730122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist