Basic Information
| Provider Information | |||||||||
| NPI: | 1457710220 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NICKSIC | ||||||||
| FirstName: | TRINA | ||||||||
| MiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1830 LAPORTE AVE | ||||||||
| Address2: | |||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805212341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704166240 | ||||||||
| FaxNumber: | 9704722369 | ||||||||
| Practice Location | |||||||||
| Address1: | 1830 LAPORTE AVE | ||||||||
| Address2: | |||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805212341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704166240 | ||||||||
| FaxNumber: | 9704722369 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2016 | ||||||||
| LastUpdateDate: | 02/22/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | 002024275 | CO | Y | Dental Providers | Dental Hygienist | 124Q00000X | 10636-16 | WI | N | Dental Providers | Dental Hygienist |
No ID Information.