Provider Demographics
NPI:1801389499
Name:ROSS, NICHOLAS ALLEN (DDS)
Entity type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:ALLEN
Last Name:ROSS
Suffix:
Gender:M
Credentials:DDS
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Mailing Address - Street 1:170 WAMPLERS LAKE RD
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:MI
Mailing Address - Zip Code:49230-9585
Mailing Address - Country:US
Mailing Address - Phone:517-592-3003
Mailing Address - Fax:517-592-5785
Practice Address - Street 1:170 WAMPLERS LAKE RD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:MI
Practice Address - Zip Code:49230-9585
Practice Address - Country:US
Practice Address - Phone:517-592-3003
Practice Address - Fax:517-592-5787
Is Sole Proprietor?:No
Enumeration Date:2018-06-08
Last Update Date:2024-09-10
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI2901022639122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1801389499Medicaid