Provider Demographics
NPI:1821832569
Name:NIC JORGE DENTAL, LLC
Entity type:Organization
Organization Name:NIC JORGE DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:NICOLAS
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:JORGE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:516-457-8005
Mailing Address - Street 1:3290 N RIDGE RD STE 180
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043-3656
Mailing Address - Country:US
Mailing Address - Phone:410-480-9111
Mailing Address - Fax:
Practice Address - Street 1:3290 N RIDGE RD STE 180
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21043-3656
Practice Address - Country:US
Practice Address - Phone:410-480-9111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-19
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty