Provider Demographics
NPI:1881779932
Name:STEVENS, NICOLE MOY (DDS)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:MOY
Last Name:STEVENS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:418 SEAPORT BLVD
Mailing Address - Street 2:
Mailing Address - City:CAPE CANAVERAL
Mailing Address - State:FL
Mailing Address - Zip Code:32920-5023
Mailing Address - Country:US
Mailing Address - Phone:321-784-3161
Mailing Address - Fax:
Practice Address - Street 1:1395 N COURTENAY PKWY
Practice Address - Street 2:SUITE 105
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-4400
Practice Address - Country:US
Practice Address - Phone:321-453-4746
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN172371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice