Provider Demographics
NPI:1407368269
Name:NICKELS, RICHARD DOUGLAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:DOUGLAS
Last Name:NICKELS
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 1:5775 RIDGETOP DR
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30504-9024
Mailing Address - Country:US
Mailing Address - Phone:770-536-3827
Mailing Address - Fax:
Practice Address - Street 1:5775 RIDGETOP DR
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30504-9024
Practice Address - Country:US
Practice Address - Phone:770-536-3827
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-01
Last Update Date:2017-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA8206122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist