Provider Demographics
NPI:1740237064
Name:NICOL, BRUCE R (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:R
Last Name:NICOL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2533 LARKIN RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-3278
Mailing Address - Country:US
Mailing Address - Phone:859-278-9376
Mailing Address - Fax:859-276-0260
Practice Address - Street 1:2533 LARKIN RD
Practice Address - Street 2:SUITE 204
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-3278
Practice Address - Country:US
Practice Address - Phone:859-278-9376
Practice Address - Fax:859-276-0260
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2016-02-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY4461122300000X, 1223S0112X, 1223P0221X, 204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No122300000XDental ProvidersDentist
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60044617Medicaid
KY64229974Medicaid