Provider Demographics
NPI:1083037931
Name:HAUS, NICOLE (DDS)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:HAUS
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 1:3001 HARBOR LN N STE 100
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-8740
Mailing Address - Country:US
Mailing Address - Phone:763-553-0451
Mailing Address - Fax:
Practice Address - Street 1:3001 HARBOR LN N STE 100
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55447-8740
Practice Address - Country:US
Practice Address - Phone:763-553-0451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-29
Last Update Date:2020-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN390200000X
MND133651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program