Provider Demographics
NPI:1265870745
Name:ACOSTA, NICHOLAS JOEL (DDS)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:JOEL
Last Name:ACOSTA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 PARK PLACE BLVD
Mailing Address - Street 2:
Mailing Address - City:WAXAHACHIE
Mailing Address - State:TX
Mailing Address - Zip Code:75165-9106
Mailing Address - Country:US
Mailing Address - Phone:972-937-4370
Mailing Address - Fax:
Practice Address - Street 1:125 PARK PLACE BLVD
Practice Address - Street 2:
Practice Address - City:WAXAHACHIE
Practice Address - State:TX
Practice Address - Zip Code:75165-9106
Practice Address - Country:US
Practice Address - Phone:972-937-4370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-06
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX28920122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist