Provider Demographics
NPI:1134863343
Name:IVANOV, NICHOLE (RDH, BS)
Entity type:Individual
Prefix:
First Name:NICHOLE
Middle Name:
Last Name:IVANOV
Suffix:
Gender:F
Credentials:RDH, BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5763 STONEBRIDGE DR SW
Mailing Address - Street 2:
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-3240
Mailing Address - Country:US
Mailing Address - Phone:231-649-7102
Mailing Address - Fax:
Practice Address - Street 1:220 W GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:CHARLEVOIX
Practice Address - State:MI
Practice Address - Zip Code:49720-1631
Practice Address - Country:US
Practice Address - Phone:231-547-7620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-24
Last Update Date:2022-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist