Provider Demographics
NPI:1710042270
Name:NICHOLS-GREGORY, WENDI (DDS)
Entity Type:Individual
Prefix:
First Name:WENDI
Middle Name:
Last Name:NICHOLS-GREGORY
Suffix:
Gender:F
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:PO BOX 125
Mailing Address - Street 2:
Mailing Address - City:HERMITAGE
Mailing Address - State:MO
Mailing Address - Zip Code:65668-0125
Mailing Address - Country:US
Mailing Address - Phone:833-789-5933
Mailing Address - Fax:417-745-0056
Practice Address - Street 1:203 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613-1623
Practice Address - Country:US
Practice Address - Phone:417-328-6334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4779122300000X
MO2016022790122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist