Provider Demographics
NPI:1104982313
Name:LUONG, NICOLE N (DDS)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:N
Last Name:LUONG
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 1:10232 SE CHAMPAGNE LN
Mailing Address - Street 2:
Mailing Address - City:HAPPY VALLEY
Mailing Address - State:OR
Mailing Address - Zip Code:97086-7843
Mailing Address - Country:US
Mailing Address - Phone:503-708-8059
Mailing Address - Fax:
Practice Address - Street 1:12720 SE STARK ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-1539
Practice Address - Country:US
Practice Address - Phone:503-252-6133
Practice Address - Fax:503-257-6886
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2014-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD7803122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR227117Medicaid