Provider Demographics
NPI:1326223843
Name:TERRY E NICHOLS DMD PA
Entity Type:Organization
Organization Name:TERRY E NICHOLS DMD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:EMMETT
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD PA
Authorized Official - Phone:850-263-6400
Mailing Address - Street 1:PO BOX 614
Mailing Address - Street 2:
Mailing Address - City:GRACEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32440-0614
Mailing Address - Country:US
Mailing Address - Phone:850-263-6400
Mailing Address - Fax:850-263-4717
Practice Address - Street 1:966 7TH AVE
Practice Address - Street 2:
Practice Address - City:GRACEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32440-2224
Practice Address - Country:US
Practice Address - Phone:850-263-6400
Practice Address - Fax:850-263-4717
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-03
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty