Provider Demographics
NPI:1558475392
Name:NICK, JERRY BOB (DDS)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:BOB
Last Name:NICK
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 1:1015 E 6TH ST
Mailing Address - Street 2:
Mailing Address - City:OKMULGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74447-4705
Mailing Address - Country:US
Mailing Address - Phone:918-758-0022
Mailing Address - Fax:918-756-2046
Practice Address - Street 1:1015 E 6TH ST
Practice Address - Street 2:
Practice Address - City:OKMULGEE
Practice Address - State:OK
Practice Address - Zip Code:74447-4705
Practice Address - Country:US
Practice Address - Phone:918-758-0022
Practice Address - Fax:918-756-2046
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK47011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice