Provider Demographics
NPI:1700448099
Name:JEZIORSKI, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:JEZIORSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 S 48TH ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62305-9102
Mailing Address - Country:US
Mailing Address - Phone:217-228-9467
Mailing Address - Fax:
Practice Address - Street 1:407 S 48TH ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62305-9102
Practice Address - Country:US
Practice Address - Phone:217-228-9467
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-08
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019032175122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist