Provider Demographics
NPI:1356907166
Name:JORGE, NICOLAS ANDREW (DMD)
Entity type:Individual
Prefix:DR
First Name:NICOLAS
Middle Name:ANDREW
Last Name:JORGE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3290 N. RIDGE RD STE#180
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043
Mailing Address - Country:US
Mailing Address - Phone:410-480-9111
Mailing Address - Fax:
Practice Address - Street 1:3290 N. RIDGE RD STE#180
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21043
Practice Address - Country:US
Practice Address - Phone:410-480-9111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-16
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD167981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice