Provider Demographics
NPI:1982196317
Name:KOLLATH, NICOLETTE TAYLOR (DDS)
Entity Type:Individual
Prefix:DR
First Name:NICOLETTE
Middle Name:TAYLOR
Last Name:KOLLATH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:NICOLETTE
Other - Middle Name:TAYLOR
Other - Last Name:KLUCAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:704 S. WEBSTER AVE #402
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301
Mailing Address - Country:US
Mailing Address - Phone:612-508-7862
Mailing Address - Fax:
Practice Address - Street 1:704 S. WEBSTER AVE #402
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301
Practice Address - Country:US
Practice Address - Phone:920-432-6894
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-01
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND140281223G0001X
WI6001156-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice