Provider Demographics
NPI:1891824934
Name:BUNCH, NICOLE MONIQUE (DDS)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MONIQUE
Last Name:BUNCH
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 1:5800 BEACH BLVD SUITE 102
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207
Mailing Address - Country:US
Mailing Address - Phone:904-330-0630
Mailing Address - Fax:904-423-0388
Practice Address - Street 1:5800 BEACH BLVD SUITE 102
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207
Practice Address - Country:US
Practice Address - Phone:904-330-0630
Practice Address - Fax:904-423-0388
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2015-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN173261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice