Provider Demographics
NPI:1568581809
Name:NICHOLSON, CONNIE JEAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:CONNIE
Middle Name:JEAN
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1852 DALE DOUGLAS DR
Mailing Address - Street 2:SUITE D
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936-4250
Mailing Address - Country:US
Mailing Address - Phone:915-778-4681
Mailing Address - Fax:915-778-6223
Practice Address - Street 1:1852 DALE DOUGLAS DR
Practice Address - Street 2:SUITE D
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-4250
Practice Address - Country:US
Practice Address - Phone:915-778-4681
Practice Address - Fax:915-778-6223
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXTX132121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice