Provider Demographics
NPI:1053576629
Name:MEDLEY, NICOLE RENEE (DDS)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:RENEE
Last Name:MEDLEY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:RENEE
Other - Last Name:GHANEM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:821 WESTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SEDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65301-2102
Mailing Address - Country:US
Mailing Address - Phone:660-826-4774
Mailing Address - Fax:660-826-1300
Practice Address - Street 1:821 WESTWOOD DR
Practice Address - Street 2:
Practice Address - City:SEDALIA
Practice Address - State:MO
Practice Address - Zip Code:65301-2102
Practice Address - Country:US
Practice Address - Phone:660-826-4774
Practice Address - Fax:660-826-1300
Is Sole Proprietor?:No
Enumeration Date:2008-07-23
Last Update Date:2012-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20080159451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice