Provider Demographics
NPI:1104719434
Name:CHAMBERLAIN, NICHOLAS (DDS)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:CHAMBERLAIN
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 1:5639 NALL AVE
Mailing Address - Street 2:
Mailing Address - City:ROELAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66202-1941
Mailing Address - Country:US
Mailing Address - Phone:479-621-3453
Mailing Address - Fax:
Practice Address - Street 1:3110 NIEDER RD
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66047-1950
Practice Address - Country:US
Practice Address - Phone:785-592-6652
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-03
Last Update Date:2025-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KS62350122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program