Provider Demographics
NPI:1093959660
Name:NICHOLSON, KEITH (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:
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:UNIVERSITY OF LOUISVILLE
Mailing Address - Street 2:501 SOUTH PRESTON ST.
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40292-0001
Mailing Address - Country:US
Mailing Address - Phone:502-852-5124
Mailing Address - Fax:
Practice Address - Street 1:100 S BROAD ST STE 1530
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19110-1026
Practice Address - Country:US
Practice Address - Phone:267-691-0606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-27
Last Update Date:2023-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY8795/8791223X0400X
NC86441223X0400X, 122300000X
IN12012234A1223X0400X
PADS0439621223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist