Provider Demographics
NPI:1376281873
Name:NICOLL, BRANDON (DMD)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:NICOLL
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 1:400 RIVERWALK TER STE 250
Mailing Address - Street 2:
Mailing Address - City:JENKS
Mailing Address - State:OK
Mailing Address - Zip Code:74037-5619
Mailing Address - Country:US
Mailing Address - Phone:918-998-0996
Mailing Address - Fax:918-235-9079
Practice Address - Street 1:5240 N TOWNE CENTRE DR STE 201
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:MO
Practice Address - Zip Code:65721-9075
Practice Address - Country:US
Practice Address - Phone:417-581-0000
Practice Address - Fax:417-582-1564
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-24
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022017990122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist