Provider Demographics
NPI:1497024111
Name:NICHOLSON, STEPHEN GRIGSBY (DDS)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:GRIGSBY
Last Name:NICHOLSON
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:P.O. BOX 389
Mailing Address - Street 2:
Mailing Address - City:BAYFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:81122
Mailing Address - Country:US
Mailing Address - Phone:970-884-9306
Mailing Address - Fax:970-884-9675
Practice Address - Street 1:30 W MILL ST
Practice Address - Street 2:
Practice Address - City:BAYFIELD
Practice Address - State:CO
Practice Address - Zip Code:81122
Practice Address - Country:US
Practice Address - Phone:970-884-9306
Practice Address - Fax:970-884-9675
Is Sole Proprietor?:No
Enumeration Date:2011-12-27
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COH-D-100898122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist