Provider Demographics
NPI:1154897627
Name:HONG, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:HONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4427 DIXIE HILL RD
Mailing Address - Street 2:APT 209
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030
Mailing Address - Country:US
Mailing Address - Phone:571-338-3104
Mailing Address - Fax:
Practice Address - Street 1:25273 NESTING SQ
Practice Address - Street 2:
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20152
Practice Address - Country:US
Practice Address - Phone:410-209-7223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-22
Last Update Date:2022-08-01
Deactivation Date:2018-12-19
Deactivation Code:
Reactivation Date:2019-01-28
Provider Licenses
StateLicense IDTaxonomies
VA0401416255122300000X
MD16626122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist