Provider Demographics
NPI:1891227831
Name:KIM, NICOLE (DMD, MSD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:DMD, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2903 50TH ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79413-4323
Mailing Address - Country:US
Mailing Address - Phone:806-589-0658
Mailing Address - Fax:806-797-0975
Practice Address - Street 1:2903 50TH ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79413-4323
Practice Address - Country:US
Practice Address - Phone:806-589-0658
Practice Address - Fax:806-797-0975
Is Sole Proprietor?:No
Enumeration Date:2017-03-29
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX327271223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics