Provider Demographics
NPI:1023740891
Name:MACDONALD, ALI NICOLE (DMD)
Entity type:Individual
Prefix:DR
First Name:ALI
Middle Name:NICOLE
Last Name:MACDONALD
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 COURT ST
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24504-1358
Mailing Address - Country:US
Mailing Address - Phone:770-324-4852
Mailing Address - Fax:
Practice Address - Street 1:239 TROJAN RD
Practice Address - Street 2:
Practice Address - City:MADISON HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:24572-5346
Practice Address - Country:US
Practice Address - Phone:434-847-4691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-29
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA04014180511223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program