Provider Demographics
NPI:1528411535
Name:ROTTJAKOB, NICOLE MARGARET (DDS)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARGARET
Last Name:ROTTJAKOB
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:951 HAMPSWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95120-3367
Mailing Address - Country:US
Mailing Address - Phone:408-439-4166
Mailing Address - Fax:
Practice Address - Street 1:951 HAMPSWOOD WAY
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95120-3367
Practice Address - Country:US
Practice Address - Phone:408-439-4166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-14
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA100340122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist