Provider Demographics
NPI:1851688816
Name:NICOLE C. FOREL DDS, LLC
Entity Type:Organization
Organization Name:NICOLE C. FOREL DDS, LLC
Other - Org Name:LIGHT STREET DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:CELESTE
Authorized Official - Last Name:FOREL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:410-659-0901
Mailing Address - Street 1:10 W MONTGOMERY ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21230-3806
Mailing Address - Country:US
Mailing Address - Phone:410-783-1340
Mailing Address - Fax:
Practice Address - Street 1:600 LIGHT ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21230-3856
Practice Address - Country:US
Practice Address - Phone:410-659-0900
Practice Address - Fax:410-659-0902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-28
Last Update Date:2011-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD135981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty