Provider Demographics
NPI:1043657810
Name:QUEZADA, NICOLE MICHELLE (DMD)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:MICHELLE
Last Name:QUEZADA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11671 ROUTE 6
Mailing Address - Street 2:
Mailing Address - City:WELLSBORO
Mailing Address - State:PA
Mailing Address - Zip Code:16901-6750
Mailing Address - Country:US
Mailing Address - Phone:570-724-2565
Mailing Address - Fax:570-724-3240
Practice Address - Street 1:11671 ROUTE 6
Practice Address - Street 2:
Practice Address - City:WELLSBORO
Practice Address - State:PA
Practice Address - Zip Code:16901-6750
Practice Address - Country:US
Practice Address - Phone:570-724-2565
Practice Address - Fax:570-724-3240
Is Sole Proprietor?:No
Enumeration Date:2013-06-03
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS027194L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist