Provider Demographics
NPI:1487993267
Name:BRIZENDINE, NICOLE RACHEL (DDS)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:RACHEL
Last Name:BRIZENDINE
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 1:6631 DIOCLETIAN WAY
Mailing Address - Street 2:
Mailing Address - City:ORANGEVALE
Mailing Address - State:CA
Mailing Address - Zip Code:95662-3205
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8101 LAGUNA BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-8202
Practice Address - Country:US
Practice Address - Phone:916-683-4333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-13
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA62139122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist