Provider Demographics
NPI:1568957629
Name:NUCKOLLS, DREW T (DDS)
Entity Type:Individual
Prefix:
First Name:DREW
Middle Name:T
Last Name:NUCKOLLS
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 1:1122 N TOPEKA ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67214-2810
Mailing Address - Country:US
Mailing Address - Phone:316-866-2000
Mailing Address - Fax:316-866-2083
Practice Address - Street 1:3417 S MERIDIAN AVE
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67217-2151
Practice Address - Country:US
Practice Address - Phone:316-866-2000
Practice Address - Fax:316-977-9312
Is Sole Proprietor?:No
Enumeration Date:2018-06-29
Last Update Date:2018-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS61441122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist