Provider Demographics
NPI:1356563290
Name:MANCINI, NICOLE M (DDS)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:M
Last Name:MANCINI
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:PO BOX 70403
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37614-1703
Mailing Address - Country:US
Mailing Address - Phone:423-433-6057
Mailing Address - Fax:423-433-6060
Practice Address - Street 1:2151 CENTURY LN
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604
Practice Address - Country:US
Practice Address - Phone:423-929-6941
Practice Address - Fax:423-929-6972
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN109191223G0001X
CT87631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ047672Medicaid