Provider Demographics
NPI:1467519744
Name:NICHOLS, DICKIE S (DDS, MS)
Entity Type:Individual
Prefix:
First Name:DICKIE
Middle Name:S
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 N 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-3218
Mailing Address - Country:US
Mailing Address - Phone:406-586-8727
Mailing Address - Fax:406-586-9382
Practice Address - Street 1:208 N 11TH AVE
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-3218
Practice Address - Country:US
Practice Address - Phone:406-586-8727
Practice Address - Fax:406-586-9382
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT13041223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT13044OtherBLUE CROSS BLUE SHIELD