Provider Demographics
NPI:1053471706
Name:NICOLL, BRIAN KEITH (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:KEITH
Last Name:NICOLL
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 1:2581 NUT TREE RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95687-6915
Mailing Address - Country:US
Mailing Address - Phone:707-451-8352
Mailing Address - Fax:707-451-8234
Practice Address - Street 1:2581 NUT TREE RD
Practice Address - Street 2:SUITE D
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95687-6915
Practice Address - Country:US
Practice Address - Phone:707-451-8352
Practice Address - Fax:707-451-8234
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA283651223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics