Provider Demographics
NPI:1457375834
Name:ANCICH, NICOLE M (DMD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:M
Last Name:ANCICH
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2208 N 30TH ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98403-3351
Mailing Address - Country:US
Mailing Address - Phone:253-383-5636
Mailing Address - Fax:253-274-0604
Practice Address - Street 1:2208 N 30TH ST
Practice Address - Street 2:SUITE 201
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98403-3351
Practice Address - Country:US
Practice Address - Phone:253-383-5636
Practice Address - Fax:253-274-0604
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000099171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice