Provider Demographics
NPI:1104050590
Name:CAROLINE, NICOLE JOLEEN (RDH)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:JOLEEN
Last Name:CAROLINE
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:BRACKEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:504 E MONROE ST
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-1400
Mailing Address - Country:US
Mailing Address - Phone:605-721-8939
Mailing Address - Fax:605-394-5217
Practice Address - Street 1:685 N LACROSSE ST
Practice Address - Street 2:SUITE 5
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-1492
Practice Address - Country:US
Practice Address - Phone:605-721-8939
Practice Address - Fax:605-394-5217
Is Sole Proprietor?:No
Enumeration Date:2009-05-13
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD879124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist