Provider Demographics
NPI:1205906633
Name:ELCANO, NICHOLE M (DDS)
Entity type:Individual
Prefix:DR
First Name:NICHOLE
Middle Name:M
Last Name:ELCANO
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 1:5017 GREEN BAY RD
Mailing Address - Street 2:SUITE 136
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-1782
Mailing Address - Country:US
Mailing Address - Phone:262-652-6121
Mailing Address - Fax:262-652-2026
Practice Address - Street 1:5017 GREEN BAY RD
Practice Address - Street 2:SUITE 136
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-1782
Practice Address - Country:US
Practice Address - Phone:262-652-6121
Practice Address - Fax:262-652-2026
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5720-015122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist