Provider Demographics
NPI:1497198873
Name:NICK, MICHAEL JOSEPH
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:NICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1240 MEADOW RD STE 300
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-3679
Mailing Address - Country:US
Mailing Address - Phone:847-272-9516
Mailing Address - Fax:847-272-9551
Practice Address - Street 1:1240 MEADOW RD
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-8300
Practice Address - Country:US
Practice Address - Phone:847-272-9516
Practice Address - Fax:847-957-9551
Is Sole Proprietor?:No
Enumeration Date:2013-04-16
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190310191223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery