Provider Demographics
NPI:1588840896
Name:NICKELL, LARRY THOMAS SR (DDS)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:THOMAS
Last Name:NICKELL
Suffix:SR
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:PO BOX 1991
Mailing Address - Street 2:
Mailing Address - City:VAN ALSTYNE
Mailing Address - State:TX
Mailing Address - Zip Code:75495-1991
Mailing Address - Country:US
Mailing Address - Phone:903-819-9075
Mailing Address - Fax:
Practice Address - Street 1:202 EAST JEFFERSON
Practice Address - Street 2:
Practice Address - City:VAN ALSTYNE
Practice Address - State:TX
Practice Address - Zip Code:75495-1991
Practice Address - Country:US
Practice Address - Phone:903-819-9075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-16
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX148811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice