Provider Demographics
NPI:1861661290
Name:KANE, NICHOLE (RDH)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:
Last Name:KANE
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:ALAMOSA
Mailing Address - State:CO
Mailing Address - Zip Code:81101-2290
Mailing Address - Country:US
Mailing Address - Phone:719-589-5161
Mailing Address - Fax:719-589-5722
Practice Address - Street 1:128 MARKET ST
Practice Address - Street 2:
Practice Address - City:ALAMOSA
Practice Address - State:CO
Practice Address - Zip Code:81101-2290
Practice Address - Country:US
Practice Address - Phone:719-589-9691
Practice Address - Fax:719-587-9148
Is Sole Proprietor?:No
Enumeration Date:2008-02-29
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO905443124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist