Provider Demographics
NPI:1104907385
Name:NICOLINO, TIM P (DDS)
Entity type:Individual
Prefix:DR
First Name:TIM
Middle Name:P
Last Name:NICOLINO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1004 E. PARK AVE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50315
Mailing Address - Country:US
Mailing Address - Phone:515-244-7428
Mailing Address - Fax:515-244-2437
Practice Address - Street 1:1004 E PARK AVE
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50315-2451
Practice Address - Country:US
Practice Address - Phone:515-244-7428
Practice Address - Fax:515-244-2437
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA69141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice