Provider Demographics
NPI:1922869338
Name:GINA NICOLOSO DMD PLLC
Entity Type:Organization
Organization Name:GINA NICOLOSO DMD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GINA
Authorized Official - Middle Name:
Authorized Official - Last Name:NICOLOSO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-509-9465
Mailing Address - Street 1:6605 SE 221ST ST
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:FL
Mailing Address - Zip Code:32640-3815
Mailing Address - Country:US
Mailing Address - Phone:352-481-2741
Mailing Address - Fax:352-481-5341
Practice Address - Street 1:6605 SE 221ST ST
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:FL
Practice Address - Zip Code:32640-3815
Practice Address - Country:US
Practice Address - Phone:352-481-2741
Practice Address - Fax:352-481-5341
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-22
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental