Provider Demographics
NPI:1205169034
Name:MACKIE, NICOLE LEILA (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:LEILA
Last Name:MACKIE
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8840 W RUSSELL RD STE 210
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-1355
Mailing Address - Country:US
Mailing Address - Phone:702-463-1300
Mailing Address - Fax:702-463-4633
Practice Address - Street 1:8840 W RUSSELL RD STE 210
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89148-1355
Practice Address - Country:US
Practice Address - Phone:702-463-1300
Practice Address - Fax:702-463-4633
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-11
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN18071122300000X
NJDI024233122300000X
NY055160-11223P0700X
NVS543C1223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Single Specialty
No122300000XDental ProvidersDentist