Provider Demographics
NPI:1225723877
Name:TINA NICHOLS DDS CORPORATION
Entity Type:Organization
Organization Name:TINA NICHOLS DDS CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:SCRUGGS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-664-7444
Mailing Address - Street 1:619 BEECHWOOD ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-3846
Mailing Address - Country:US
Mailing Address - Phone:150-166-4744
Mailing Address - Fax:501-232-9053
Practice Address - Street 1:619 BEECHWOOD ST
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-3846
Practice Address - Country:US
Practice Address - Phone:150-166-4744
Practice Address - Fax:501-232-9053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-10
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental