Provider Demographics
NPI:1659443802
Name:NICEWANDER, JACK E (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:E
Last Name:NICEWANDER
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 1:5511 E 82ND ST
Mailing Address - Street 2:SUITE F
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-4698
Mailing Address - Country:US
Mailing Address - Phone:317-842-1903
Mailing Address - Fax:317-849-8054
Practice Address - Street 1:5511 E 82ND ST
Practice Address - Street 2:SUITE F
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-4698
Practice Address - Country:US
Practice Address - Phone:317-842-1903
Practice Address - Fax:317-849-8054
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12007501A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice