Provider Demographics
NPI:1053446450
Name:NICHOLSON, JASON DEWAYNE (DDS)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:DEWAYNE
Last Name:NICHOLSON
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:PO BOX 669
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:TN
Mailing Address - Zip Code:37307
Mailing Address - Country:US
Mailing Address - Phone:423-338-8519
Mailing Address - Fax:423-338-8576
Practice Address - Street 1:6151 HWY 411
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:TN
Practice Address - Zip Code:37307
Practice Address - Country:US
Practice Address - Phone:423-338-8519
Practice Address - Fax:423-338-8576
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7391122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist