Provider Demographics
NPI:1659317352
Name:NICHOLS, MARK ROBERTS (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ROBERTS
Last Name:NICHOLS
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 1:3651 HIGHWAY 59 N
Mailing Address - Street 2:
Mailing Address - City:GROVE
Mailing Address - State:OK
Mailing Address - Zip Code:74344-3705
Mailing Address - Country:US
Mailing Address - Phone:918-786-4084
Mailing Address - Fax:918-786-4984
Practice Address - Street 1:3651 HIGHWAY 59 N
Practice Address - Street 2:
Practice Address - City:GROVE
Practice Address - State:OK
Practice Address - Zip Code:74344-3705
Practice Address - Country:US
Practice Address - Phone:918-786-4084
Practice Address - Fax:918-786-4984
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK44241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice