Provider Demographics
NPI:1194830711
Name:NICOL, BRIAN SCOTT (DDS)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:SCOTT
Last Name:NICOL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:B
Other - Middle Name:SCOTT
Other - Last Name:NICOL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:PO BOX 606
Mailing Address - Street 2:214 LARKIN ST
Mailing Address - City:TOMAH
Mailing Address - State:WI
Mailing Address - Zip Code:54660-0606
Mailing Address - Country:US
Mailing Address - Phone:608-372-3298
Mailing Address - Fax:608-372-3128
Practice Address - Street 1:214 LARKIN ST
Practice Address - Street 2:
Practice Address - City:TOMAH
Practice Address - State:WI
Practice Address - Zip Code:54660-0606
Practice Address - Country:US
Practice Address - Phone:608-372-3298
Practice Address - Fax:608-372-3128
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI50011831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33563100Medicaid
WI33563100Medicaid