Provider Demographics
NPI:1619041076
Name:NICHOLS, STEPHANIE MARIE (DMD)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:MARIE
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4259 ROBERT C. BYRD DR
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801
Mailing Address - Country:US
Mailing Address - Phone:301-351-3670
Mailing Address - Fax:
Practice Address - Street 1:4259 ROBERT C. BYRD DR
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801
Practice Address - Country:US
Practice Address - Phone:301-351-3670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV4250122300000X
VA04014106811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice