Provider Demographics
NPI:1386794733
Name:NICASSIO, RALPH ANTHONY (DDS)
Entity type:Individual
Prefix:
First Name:RALPH
Middle Name:ANTHONY
Last Name:NICASSIO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11936 IMPERIAL HWY
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CA
Mailing Address - Zip Code:90650-3000
Mailing Address - Country:US
Mailing Address - Phone:562-868-7768
Mailing Address - Fax:562-863-2369
Practice Address - Street 1:11936 IMPERIAL HWY
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CA
Practice Address - Zip Code:90650-3000
Practice Address - Country:US
Practice Address - Phone:562-868-7768
Practice Address - Fax:562-863-2369
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33642122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist