Provider Demographics
NPI:1720398118
Name:NICHOLSON FAMILY DENTAL LLC
Entity Type:Organization
Organization Name:NICHOLSON FAMILY DENTAL LLC
Other - Org Name:SMALL SMILES DENTAL CENTER OF MUNCIE LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:NICHOLSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:260-824-2811
Mailing Address - Street 1:116 E DUSTMAN RD
Mailing Address - Street 2:STE A
Mailing Address - City:BLUFFTON
Mailing Address - State:IN
Mailing Address - Zip Code:46714
Mailing Address - Country:US
Mailing Address - Phone:260-824-7195
Mailing Address - Fax:260-824-2812
Practice Address - Street 1:116 E DUSTMAN RD
Practice Address - Street 2:STE A
Practice Address - City:BLUFFTON
Practice Address - State:IN
Practice Address - Zip Code:46714
Practice Address - Country:US
Practice Address - Phone:260-824-7195
Practice Address - Fax:260-824-2812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-19
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201004460Medicaid