Provider Demographics
NPI:1245244474
Name:NUCKOLS, CHARLES THOMAS (DMD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:THOMAS
Last Name:NUCKOLS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:627 EASTWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42103-1688
Mailing Address - Country:US
Mailing Address - Phone:270-843-4341
Mailing Address - Fax:270-746-9551
Practice Address - Street 1:627 EASTWOOD AVE
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103-1688
Practice Address - Country:US
Practice Address - Phone:270-843-4341
Practice Address - Fax:270-746-9551
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2008-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY33991223S0112X, 204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000212083OtherANTHEM PROVIDER ID
KY6389OtherDORAL DENTAL ID
KY1115671OtherPASSPORT GROUP PIN
KY60033990Medicaid
KY64033996Medicaid
KY1069982OtherPASSPORT HEALTH ID PIN
KY1115671OtherPASSPORT GROUP PIN
KY6389OtherDORAL DENTAL ID