Provider Demographics
NPI:1558794396
Name:DR. PATRICIA NICKLAS
Entity Type:Organization
Organization Name:DR. PATRICIA NICKLAS
Other - Org Name:NICKLAS DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:NICKLAS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:843-412-4036
Mailing Address - Street 1:9565 HIGHWAY 78
Mailing Address - Street 2:UNIT 600B
Mailing Address - City:LADSON
Mailing Address - State:SC
Mailing Address - Zip Code:29456-4118
Mailing Address - Country:US
Mailing Address - Phone:843-412-4036
Mailing Address - Fax:
Practice Address - Street 1:9565 HIGHWAY 78
Practice Address - Street 2:UNIT 600B
Practice Address - City:LADSON
Practice Address - State:SC
Practice Address - Zip Code:29456-4118
Practice Address - Country:US
Practice Address - Phone:843-412-4036
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-15
Last Update Date:2013-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC46261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1023230414Medicaid
SCZX4626Medicaid