Provider Demographics
NPI:1669547816
Name:NOLLIE, GLORIA JEAN (DDS, MCLD)
Entity type:Individual
Prefix:MRS
First Name:GLORIA
Middle Name:JEAN
Last Name:NOLLIE
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Gender:F
Credentials:DDS, MCLD
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Other - First Name:
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Mailing Address - Street 1:5740 WINDMILL WAY
Mailing Address - Street 2:SUITE 16
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-1379
Mailing Address - Country:US
Mailing Address - Phone:916-331-0842
Mailing Address - Fax:916-482-4287
Practice Address - Street 1:5740 WINDMILL WAY
Practice Address - Street 2:SUITE 16
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-1379
Practice Address - Country:US
Practice Address - Phone:916-331-0842
Practice Address - Fax:916-482-4287
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2011-06-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA250131223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics