Provider Demographics
NPI:1043882103
Name:NICHOLS, BROCK WESLEY (DDS)
Entity Type:Individual
Prefix:DR
First Name:BROCK
Middle Name:WESLEY
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10041 OAKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73025-5007
Mailing Address - Country:US
Mailing Address - Phone:405-436-5583
Mailing Address - Fax:
Practice Address - Street 1:3703 N KICKAPOO AVE
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74804-1703
Practice Address - Country:US
Practice Address - Phone:405-275-0640
Practice Address - Fax:405-225-3008
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-16
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD114491223G0001X
OK7763122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice