Provider Demographics
NPI:1194177337
Name:NICELY, KONGYAN DREW (DDS)
Entity type:Individual
Prefix:
First Name:KONGYAN
Middle Name:DREW
Last Name:NICELY
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 1:317 S MARKET ST
Mailing Address - Street 2:P.O. BOX 1480
Mailing Address - City:GOLIAD
Mailing Address - State:TX
Mailing Address - Zip Code:77963-4167
Mailing Address - Country:US
Mailing Address - Phone:361-645-2381
Mailing Address - Fax:
Practice Address - Street 1:317 S MARKET ST
Practice Address - Street 2:
Practice Address - City:GOLIAD
Practice Address - State:TX
Practice Address - Zip Code:77963-4167
Practice Address - Country:US
Practice Address - Phone:361-645-2381
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-12
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31979122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist