Provider Demographics
NPI:1457433617
Name:PADOVAN-LAGRASTA, NICOLE (DMD, PA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:PADOVAN-LAGRASTA
Suffix:
Gender:F
Credentials:DMD, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 E UNION AVE
Mailing Address - Street 2:
Mailing Address - City:BOUND BROOK
Mailing Address - State:NJ
Mailing Address - Zip Code:08805-1713
Mailing Address - Country:US
Mailing Address - Phone:732-469-4424
Mailing Address - Fax:732-469-9138
Practice Address - Street 1:105 E UNION AVE
Practice Address - Street 2:
Practice Address - City:BOUND BROOK
Practice Address - State:NJ
Practice Address - Zip Code:08805-1713
Practice Address - Country:US
Practice Address - Phone:732-469-4424
Practice Address - Fax:732-469-9138
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ0205371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice