Provider Demographics
NPI:1336340165
Name:NICHOLAS POBLETE, D.D.S., INC.
Entity type:Organization
Organization Name:NICHOLAS POBLETE, D.D.S., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:ELLIS
Authorized Official - Last Name:POBLETE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:209-521-6822
Mailing Address - Street 1:1316 COFFEE RD
Mailing Address - Street 2:BLDG. C
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-3191
Mailing Address - Country:US
Mailing Address - Phone:209-521-6822
Mailing Address - Fax:209-521-0466
Practice Address - Street 1:1316 COFFEE RD
Practice Address - Street 2:BLDG. C
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-3191
Practice Address - Country:US
Practice Address - Phone:209-521-6822
Practice Address - Fax:209-521-0466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-30
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49190122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty