Provider Demographics
NPI:1356727184
Name:O'PALLICK, NICOLE (DDS)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:
Last Name:O'PALLICK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:ROSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:27140 MANOR CIR
Mailing Address - Street 2:
Mailing Address - City:VALENCIA
Mailing Address - State:CA
Mailing Address - Zip Code:91354-2691
Mailing Address - Country:US
Mailing Address - Phone:541-971-3183
Mailing Address - Fax:
Practice Address - Street 1:755 W RANCHO VISTA BLVD
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93551-3735
Practice Address - Country:US
Practice Address - Phone:661-265-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-04
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA648231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1356727184Medicaid