Provider Demographics
NPI:1912046319
Name:NICOLA, ROBERT LEON (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:LEON
Last Name:NICOLA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1522 W CENTRE AVENUE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024
Mailing Address - Country:US
Mailing Address - Phone:269-327-6765
Mailing Address - Fax:269-327-1138
Practice Address - Street 1:1522 W CENTRE AVENUE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024
Practice Address - Country:US
Practice Address - Phone:269-327-6765
Practice Address - Fax:269-327-1138
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901016827122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
V04406Medicare UPIN