Provider Demographics
NPI:1770076077
Name:NONG, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:NONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:717 BROADWAY BLVD APT 214S
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64105-2092
Mailing Address - Country:US
Mailing Address - Phone:314-604-7103
Mailing Address - Fax:
Practice Address - Street 1:13051 S US HIGHWAY 71
Practice Address - Street 2:
Practice Address - City:GRANDVIEW
Practice Address - State:MO
Practice Address - Zip Code:64030-2525
Practice Address - Country:US
Practice Address - Phone:816-966-9450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-11
Last Update Date:2018-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018019392122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist