Provider Demographics
NPI:1962648618
Name:SIARA-OLDS, NICOLE JULIA (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:JULIA
Last Name:SIARA-OLDS
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4232 THOMAS AVE
Mailing Address - Street 2:
Mailing Address - City:BERKLEY
Mailing Address - State:MI
Mailing Address - Zip Code:48072-3170
Mailing Address - Country:US
Mailing Address - Phone:248-298-6499
Mailing Address - Fax:248-246-6587
Practice Address - Street 1:38110 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:MI
Practice Address - Zip Code:48184-2842
Practice Address - Country:US
Practice Address - Phone:734-728-1705
Practice Address - Fax:734-728-1762
Is Sole Proprietor?:No
Enumeration Date:2008-12-31
Last Update Date:2008-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901018908122300000X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist