Provider Demographics
NPI:1427189224
Name:NICHOLS, MICHAEL R (DMD, MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:R
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:266 KATHERINE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39232-8801
Mailing Address - Country:US
Mailing Address - Phone:601-420-3223
Mailing Address - Fax:601-420-3054
Practice Address - Street 1:266 KATHERINE DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39232-8801
Practice Address - Country:US
Practice Address - Phone:601-420-3223
Practice Address - Fax:601-420-3054
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3119-001223S0112X
MSOS-340-00174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Not Answered174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00213548Medicaid
MSU85144Medicare UPIN