Provider Demographics
NPI:1164645784
Name:NICHOLS, DONNA L (DMD)
Entity Type:Individual
Prefix:DR
First Name:DONNA
Middle Name:L
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:MRS
Other - First Name:DONNA
Other - Middle Name:L
Other - Last Name:BUSTAMANTE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3005 ENTERPRISE RD E
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33759-1304
Mailing Address - Country:US
Mailing Address - Phone:727-789-6347
Mailing Address - Fax:727-796-8364
Practice Address - Street 1:3005 ENTERPRISE RD E
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33759-1304
Practice Address - Country:US
Practice Address - Phone:727-789-6347
Practice Address - Fax:727-796-8364
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN00133111223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry