Provider Demographics
NPI:1104062207
Name:DEMARS, NICHOLE LEE (DDS)
Entity type:Individual
Prefix:DR
First Name:NICHOLE
Middle Name:LEE
Last Name:DEMARS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:NICHOLE
Other - Middle Name:
Other - Last Name:DEMARS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:2155 W ROSCOE ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-6260
Mailing Address - Country:US
Mailing Address - Phone:773-528-3384
Mailing Address - Fax:773-528-3604
Practice Address - Street 1:3976 IL ROUTE 22 STE E
Practice Address - Street 2:
Practice Address - City:LONG GROVE
Practice Address - State:IL
Practice Address - Zip Code:60047-5318
Practice Address - Country:US
Practice Address - Phone:847-719-1973
Practice Address - Fax:847-719-1975
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-20
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0259861223G0001X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL26-3663111OtherALL INSURANCE CARRIERS