Basic Information
| Provider Information | |||||||||
| NPI: | 1083063754 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOLBA | ||||||||
| FirstName: | NICHOLAS | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301 EXPLORER ST | ||||||||
| Address2: | |||||||||
| City: | GWINN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 498412813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9064831177 | ||||||||
| FaxNumber: | 9063723230 | ||||||||
| Practice Location | |||||||||
| Address1: | 56720 CALUMET AVE | ||||||||
| Address2: | |||||||||
| City: | CALUMET | ||||||||
| State: | MI | ||||||||
| PostalCode: | 499131967 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9064831177 | ||||||||
| FaxNumber: | 9063723230 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2016 | ||||||||
| LastUpdateDate: | 03/08/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 2901021897 | MI | Y | Dental Providers | Dentist | General Practice |
No ID Information.