Provider Demographics
NPI:1679792006
Name:NICKOU, CHARLES A (DMD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:A
Last Name:NICKOU
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 BOSTON RD
Mailing Address - Street 2:
Mailing Address - City:NEWBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01951-1602
Mailing Address - Country:US
Mailing Address - Phone:978-465-1878
Mailing Address - Fax:
Practice Address - Street 1:16 HARRIS ST
Practice Address - Street 2:
Practice Address - City:NEWBURYPORT
Practice Address - State:MA
Practice Address - Zip Code:01950-2603
Practice Address - Country:US
Practice Address - Phone:978-462-9643
Practice Address - Fax:978-462-6167
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA15915122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAX08063OtherBLUE CROSS BLUE SHIELD ID