Provider Demographics
NPI:1205273042
Name:TRIPP, NICOLE LEIGH (DDS)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:LEIGH
Last Name:TRIPP
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 BIRCH AVE S
Mailing Address - Street 2:
Mailing Address - City:MAPLE LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55358-4570
Mailing Address - Country:US
Mailing Address - Phone:320-963-3794
Mailing Address - Fax:
Practice Address - Street 1:57 BIRCH AVE S
Practice Address - Street 2:
Practice Address - City:MAPLE LAKE
Practice Address - State:MN
Practice Address - Zip Code:55358-4570
Practice Address - Country:US
Practice Address - Phone:320-963-3794
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-03
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND132341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice