Provider Demographics
NPI:1689067928
Name:JACK E NICEWANDER
Entity Type:Organization
Organization Name:JACK E NICEWANDER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:E
Authorized Official - Last Name:NICEWANDER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-842-1903
Mailing Address - Street 1:5511 E 82ND ST
Mailing Address - Street 2:STE 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:STE 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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-11
Last Update Date:2015-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12007501A261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental