Provider Demographics
NPI:1376833137
Name:NICHOLS, SHELLY MARIE (RDH)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:MARIE
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18945 FM 2252
Mailing Address - Street 2:SUITE 115
Mailing Address - City:GARDEN RIDGE
Mailing Address - State:TX
Mailing Address - Zip Code:78266-2562
Mailing Address - Country:US
Mailing Address - Phone:210-564-6602
Mailing Address - Fax:210-651-0029
Practice Address - Street 1:18945 FM 2252
Practice Address - Street 2:SUITE 115
Practice Address - City:GARDEN RIDGE
Practice Address - State:TX
Practice Address - Zip Code:78266-2562
Practice Address - Country:US
Practice Address - Phone:210-564-6602
Practice Address - Fax:210-651-0029
Is Sole Proprietor?:No
Enumeration Date:2011-04-13
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDH 17325124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist