Provider Demographics
NPI:1932380433
Name:TEJEDA-NICHOLS, MAX MARCO (CD)
Entity Type:Individual
Prefix:DR
First Name:MAX
Middle Name:MARCO
Last Name:TEJEDA-NICHOLS
Suffix:
Gender:M
Credentials:CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 LINCOLN HWY
Mailing Address - Street 2:
Mailing Address - City:ROCHELLE
Mailing Address - State:IL
Mailing Address - Zip Code:61068-1642
Mailing Address - Country:US
Mailing Address - Phone:815-562-9742
Mailing Address - Fax:
Practice Address - Street 1:409 LINCOLN HWY
Practice Address - Street 2:
Practice Address - City:ROCHELLE
Practice Address - State:IL
Practice Address - Zip Code:61068-1642
Practice Address - Country:US
Practice Address - Phone:815-562-9742
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-26
Last Update Date:2007-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-019969122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist