Provider Demographics
NPI:1386669257
Name:NICKERSON, GARY S (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:S
Last Name:NICKERSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8330 W 145TH PL
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-2867
Mailing Address - Country:US
Mailing Address - Phone:708-349-8677
Mailing Address - Fax:
Practice Address - Street 1:2833 LINCOLN ST
Practice Address - Street 2:SUITE 1
Practice Address - City:HIGHLAND
Practice Address - State:IN
Practice Address - Zip Code:46322-1924
Practice Address - Country:US
Practice Address - Phone:219-838-2007
Practice Address - Fax:219-972-6267
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009939A1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN130765OtherUNITED CONCORDIA
IN755187OtherUNITED CONCORDIA