Provider Demographics
NPI:1649201443
Name:LES E. NICHOLSON D.D.S. INC.
Entity Type:Organization
Organization Name:LES E. NICHOLSON D.D.S. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LES
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:NICHOLSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:304-329-1691
Mailing Address - Street 1:PO BOX 486
Mailing Address - Street 2:
Mailing Address - City:KINGWOOD
Mailing Address - State:WV
Mailing Address - Zip Code:26537-0486
Mailing Address - Country:US
Mailing Address - Phone:304-329-1691
Mailing Address - Fax:304-329-3382
Practice Address - Street 1:112 E COURT ST
Practice Address - Street 2:
Practice Address - City:KINGWOOD
Practice Address - State:WV
Practice Address - Zip Code:26537-1437
Practice Address - Country:US
Practice Address - Phone:304-329-1691
Practice Address - Fax:304-329-3382
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2331122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV42673OtherUNITED CONCORDIA CORP #
WV0136227001Medicaid