Provider Demographics
NPI:1124736723
Name:NICOLELLO, SAMANTHA ANNE (RDH)
Entity type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:ANNE
Last Name:NICOLELLO
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4044 N LEGACY WOODS AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-4480
Mailing Address - Country:US
Mailing Address - Phone:208-871-0760
Mailing Address - Fax:
Practice Address - Street 1:4044 N LEGACY WOODS AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-4480
Practice Address - Country:US
Practice Address - Phone:208-871-0760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-11
Last Update Date:2022-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDDH-3204124Q00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No124Q00000XDental ProvidersDental Hygienist