Provider Demographics
NPI:1982001566
Name:FERNANDEZ, NICOLE KI
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:KI
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7321 ASPIRE CT
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89113-1183
Mailing Address - Country:US
Mailing Address - Phone:808-255-4748
Mailing Address - Fax:
Practice Address - Street 1:6525 N DECATUR BLVD
Practice Address - Street 2:SUITE 150
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89131-2992
Practice Address - Country:US
Practice Address - Phone:702-577-1941
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-26
Last Update Date:2015-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV6609122300000X
NJ22DI02589600122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist