Provider Demographics
NPI:1619509460
Name:NIKCHEVICH, NICHOLAS T (DDS)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:T
Last Name:NIKCHEVICH
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 1:2753 WAVERLY DR APT 906
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90039-2788
Mailing Address - Country:US
Mailing Address - Phone:805-728-5583
Mailing Address - Fax:
Practice Address - Street 1:1100 N STATE ST RM A3C
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-5000
Practice Address - Country:US
Practice Address - Phone:805-728-5583
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-10
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA1055831223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program