Provider Demographics
NPI:1740623578
Name:NICHOLS, LEANNE MALIA CASSELLA (DDS)
Entity type:Individual
Prefix:DR
First Name:LEANNE
Middle Name:MALIA CASSELLA
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:LEANNE
Other - Middle Name:MALIA
Other - Last Name:CASSELLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2055 W 136TH AVE
Mailing Address - Street 2:SUITE 136
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80023-9308
Mailing Address - Country:US
Mailing Address - Phone:303-452-2800
Mailing Address - Fax:
Practice Address - Street 1:2055 W 136TH AVE
Practice Address - Street 2:SUITE 136
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80023-9308
Practice Address - Country:US
Practice Address - Phone:303-452-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-11
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.002022351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice