Provider Demographics
NPI:1568487890
Name:NICHOLS, JULIAN WADE (DMD)
Entity Type:Individual
Prefix:DR
First Name:JULIAN
Middle Name:WADE
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13089 OCEAN HWY
Mailing Address - Street 2:D-4
Mailing Address - City:PAWLEYS ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29585-7140
Mailing Address - Country:US
Mailing Address - Phone:843-979-3636
Mailing Address - Fax:
Practice Address - Street 1:13089 OCEAN HWY
Practice Address - Street 2:D4
Practice Address - City:PAWLEYS ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29585-7140
Practice Address - Country:US
Practice Address - Phone:843-979-3636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2016-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC19561223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC19560Medicaid