Provider Demographics
NPI:1598086001
Name:NICHOLSON, JASON DANIEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:DANIEL
Last Name:NICHOLSON
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 1:1355 N UNIVERSITY AVE SUITE #110
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604
Mailing Address - Country:US
Mailing Address - Phone:385-309-0309
Mailing Address - Fax:
Practice Address - Street 1:2401 NW 23RD ST
Practice Address - Street 2:SUITE 23
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73107-2442
Practice Address - Country:US
Practice Address - Phone:405-942-0337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-18
Last Update Date:2016-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9410532-99231223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics