Provider Demographics
NPI:1407158876
Name:NICHOLAS THACKER DDS INC
Entity Type:Organization
Organization Name:NICHOLAS THACKER DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:ADAM
Authorized Official - Last Name:THACKER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:619-449-6555
Mailing Address - Street 1:8770 CUYAMACA ST STE 1
Mailing Address - Street 2:
Mailing Address - City:SANTEE
Mailing Address - State:CA
Mailing Address - Zip Code:92071-4282
Mailing Address - Country:US
Mailing Address - Phone:619-449-6555
Mailing Address - Fax:619-258-8819
Practice Address - Street 1:8770 CUYAMACA ST STE 1
Practice Address - Street 2:
Practice Address - City:SANTEE
Practice Address - State:CA
Practice Address - Zip Code:92071-4282
Practice Address - Country:US
Practice Address - Phone:619-449-6555
Practice Address - Fax:619-258-8819
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-17
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA571841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty