Provider Demographics
NPI:1659812741
Name:NICHOLS, CHRISTIANA (RDH)
Entity Type:Individual
Prefix:
First Name:CHRISTIANA
Middle Name:
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:CHRISTIANA
Other - Middle Name:
Other - Last Name:CARLSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDH
Mailing Address - Street 1:400 S TOWNLINE RD
Mailing Address - Street 2:
Mailing Address - City:WAUTOMA
Mailing Address - State:WI
Mailing Address - Zip Code:54982-6922
Mailing Address - Country:US
Mailing Address - Phone:920-787-5514
Mailing Address - Fax:920-787-4737
Practice Address - Street 1:400 S TOWNLINE RD
Practice Address - Street 2:
Practice Address - City:WAUTOMA
Practice Address - State:WI
Practice Address - Zip Code:54982-6922
Practice Address - Country:US
Practice Address - Phone:920-787-5514
Practice Address - Fax:920-787-4737
Is Sole Proprietor?:No
Enumeration Date:2017-03-09
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9821-16124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist