Provider Demographics
NPI:1396242178
Name:MAHAN, NICOLE (RDH)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MAHAN
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 1:3140 CLEARWATER DR
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305-7131
Mailing Address - Country:US
Mailing Address - Phone:928-445-5959
Mailing Address - Fax:928-445-5958
Practice Address - Street 1:3140 CLEARWATER DR
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-7131
Practice Address - Country:US
Practice Address - Phone:928-445-5959
Practice Address - Fax:928-445-5958
Is Sole Proprietor?:No
Enumeration Date:2018-04-09
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZH007639124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist