Provider Demographics
NPI:1619060738
Name:NICHOLSON, RICHARD I (DDS)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:I
Last Name:NICHOLSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:G
Other - Middle Name:RICHARD
Other - Last Name:NICHOLSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:825 US 1
Mailing Address - Street 2:SUITE 250
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33477
Mailing Address - Country:US
Mailing Address - Phone:561-744-6121
Mailing Address - Fax:561-744-8707
Practice Address - Street 1:825 451
Practice Address - Street 2:SUITE 250
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33477
Practice Address - Country:US
Practice Address - Phone:561-744-6121
Practice Address - Fax:561-744-8707
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN9468122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist