Provider Demographics
NPI:1285451880
Name:NICKERSON, STEPHANIE L (RDH)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:L
Last Name:NICKERSON
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 1:514 OHANA NUI CIR
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96818-4425
Mailing Address - Country:US
Mailing Address - Phone:813-380-1341
Mailing Address - Fax:
Practice Address - Street 1:480 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:JBPHH
Practice Address - State:HI
Practice Address - Zip Code:96860-4908
Practice Address - Country:US
Practice Address - Phone:808-473-1880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-24
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDH2400124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist