Provider Demographics
NPI:1457515355
Name:JOHNSON, NICHOLE STACHEWICZ (DMD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLE
Middle Name:STACHEWICZ
Last Name:JOHNSON
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 1:4206 E LAKE RD
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16511-1357
Mailing Address - Country:US
Mailing Address - Phone:814-899-0602
Mailing Address - Fax:814-898-0990
Practice Address - Street 1:4206 E LAKE RD
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16511-1357
Practice Address - Country:US
Practice Address - Phone:814-899-0602
Practice Address - Fax:814-898-0990
Is Sole Proprietor?:No
Enumeration Date:2008-07-10
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADSO374681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice