Provider Demographics
NPI:1760757264
Name:NICHOLS, WILLIAM R (DDS)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:R
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 1:4701 LOMAS BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110
Mailing Address - Country:US
Mailing Address - Phone:505-433-5204
Mailing Address - Fax:
Practice Address - Street 1:751 TRINITY DR STE 305
Practice Address - Street 2:
Practice Address - City:LOS ALAMOS
Practice Address - State:NM
Practice Address - Zip Code:87544-3357
Practice Address - Country:US
Practice Address - Phone:505-661-9060
Practice Address - Fax:505-738-0338
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-15
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD3624122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1568883338Medicaid