Provider Demographics
NPI:1750497798
Name:NICHOLS, JOSEPH ROBERT (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:ROBERT
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61448-1351
Mailing Address - Country:US
Mailing Address - Phone:309-289-8609
Mailing Address - Fax:309-289-2583
Practice Address - Street 1:228 E MAIN ST
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:IL
Practice Address - Zip Code:61448-1351
Practice Address - Country:US
Practice Address - Phone:309-289-8609
Practice Address - Fax:309-289-2583
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice