Provider Demographics
NPI:1114187945
Name:NICHOLS, BART N (DDS)
Entity Type:Individual
Prefix:DR
First Name:BART
Middle Name:N
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 1:4340 MCCULLOUGH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212-1909
Mailing Address - Country:US
Mailing Address - Phone:210-822-8866
Mailing Address - Fax:210-822-1044
Practice Address - Street 1:4340 MCCULLOUGH AVE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-1909
Practice Address - Country:US
Practice Address - Phone:210-822-8866
Practice Address - Fax:210-822-1044
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-16
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX128721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice