Provider Demographics
NPI:1649236696
Name:NIKOLAUS, BRENT EUGENE (DDS)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:EUGENE
Last Name:NIKOLAUS
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 1:3810 POINT CLEAR DR
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-8193
Mailing Address - Country:US
Mailing Address - Phone:228-818-9412
Mailing Address - Fax:
Practice Address - Street 1:81ST DS/SGD
Practice Address - Street 2:606 FISHER ST, BLDG 0824
Practice Address - City:KEESLER AFB
Practice Address - State:MS
Practice Address - Zip Code:39534-2567
Practice Address - Country:US
Practice Address - Phone:228-377-5890
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS00000045931223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics