Provider Demographics
NPI:1679202485
Name:NOTHONGKHAM, NICOLE (DDS)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:NOTHONGKHAM
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 1:1925 82ND AVE N
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55444-1573
Mailing Address - Country:US
Mailing Address - Phone:763-229-7577
Mailing Address - Fax:
Practice Address - Street 1:4803 MILLER TRUNK HWY STE B
Practice Address - Street 2:
Practice Address - City:HERMANTOWN
Practice Address - State:MN
Practice Address - Zip Code:55811-4804
Practice Address - Country:US
Practice Address - Phone:218-722-7770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-07
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND14748122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist