Provider Demographics
NPI:1982807632
Name:WASCOM, NICOLE SUBERVILLE (DDS)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:SUBERVILLE
Last Name:WASCOM
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 1:22464 HIGHWAY 435
Mailing Address - Street 2:
Mailing Address - City:ABITA SPRINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70420-2206
Mailing Address - Country:US
Mailing Address - Phone:985-893-7835
Mailing Address - Fax:985-893-3867
Practice Address - Street 1:22464 HIGHWAY 435
Practice Address - Street 2:
Practice Address - City:ABITA SPRINGS
Practice Address - State:LA
Practice Address - Zip Code:70420-2206
Practice Address - Country:US
Practice Address - Phone:985-893-7835
Practice Address - Fax:985-893-3867
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5288122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1852881Medicaid