Provider Demographics
NPI:1588087027
Name:MAHONEY, NICOLE (DMD)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MAHONEY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9040 HAWLEY DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-6120
Mailing Address - Country:US
Mailing Address - Phone:435-229-5088
Mailing Address - Fax:
Practice Address - Street 1:9040 HAWLEY DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-6120
Practice Address - Country:US
Practice Address - Phone:435-229-5088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-03
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX314431223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics