Provider Demographics
NPI:1952591661
Name:PROVENZANO, NICOLE (DDS)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:
Last Name:PROVENZANO
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 1:8046 JAMAICA AVE
Mailing Address - Street 2:
Mailing Address - City:WOODHAVEN
Mailing Address - State:NY
Mailing Address - Zip Code:11421-1901
Mailing Address - Country:US
Mailing Address - Phone:718-296-8100
Mailing Address - Fax:
Practice Address - Street 1:3156 STEINWAY ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11103-3909
Practice Address - Country:US
Practice Address - Phone:718-721-4700
Practice Address - Fax:718-204-5641
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-29
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY050787122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist