Provider Demographics
NPI:1245537604
Name:GHAZZOULI, CANDICE NICOLE (DMD)
Entity type:Individual
Prefix:DR
First Name:CANDICE
Middle Name:NICOLE
Last Name:GHAZZOULI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:CANDICE
Other - Middle Name:NICOLE
Other - Last Name:CARPENTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:1660 SYCAMORE RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:MONTOURSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17754-9314
Mailing Address - Country:US
Mailing Address - Phone:570-323-4819
Mailing Address - Fax:570-323-7057
Practice Address - Street 1:1660 SYCAMORE RD
Practice Address - Street 2:SUITE A
Practice Address - City:MONTOURSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17754-9314
Practice Address - Country:US
Practice Address - Phone:570-323-4819
Practice Address - Fax:570-323-7057
Is Sole Proprietor?:No
Enumeration Date:2011-02-22
Last Update Date:2011-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0374711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice