Basic Information
| Provider Information | |||||||||
| NPI: | 1104050590 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAROLINE | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | JOLEEN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RDH | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BRACKEN | ||||||||
| OtherFirstName: | NICOLE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 504 E MONROE ST | ||||||||
| Address2: | |||||||||
| City: | RAPID CITY | ||||||||
| State: | SD | ||||||||
| PostalCode: | 577011400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6057218939 | ||||||||
| FaxNumber: | 6053945217 | ||||||||
| Practice Location | |||||||||
| Address1: | 685 N LACROSSE ST | ||||||||
| Address2: | SUITE 5 | ||||||||
| City: | RAPID CITY | ||||||||
| State: | SD | ||||||||
| PostalCode: | 577011492 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6057218939 | ||||||||
| FaxNumber: | 6053945217 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2009 | ||||||||
| LastUpdateDate: | 05/13/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | 879 | SD | Y | Dental Providers | Dental Hygienist |
No ID Information.