Provider Demographics
NPI:1407834120
Name:NICHOLAS, KENTON C (DDS)
Entity Type:Individual
Prefix:DR
First Name:KENTON
Middle Name:C
Last Name:NICHOLAS
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 1:1900 16TH ST
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80631-5114
Mailing Address - Country:US
Mailing Address - Phone:970-350-2458
Mailing Address - Fax:970-392-4715
Practice Address - Street 1:1900 16TH ST
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80631-5114
Practice Address - Country:US
Practice Address - Phone:970-350-2458
Practice Address - Fax:970-392-4715
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO604204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
COP00944805OtherMEDICARE RAILROAD CARRIER PTAN
CO02006047Medicaid
COT60254Medicare UPIN
COP00944805OtherMEDICARE RAILROAD CARRIER PTAN
COCOA102115Medicare PIN