Provider Demographics
NPI:1780004580
Name:NICHOLS, BROOKE D (RDH, BS)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:D
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:RDH, BS
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 7331
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CO
Mailing Address - Zip Code:81620-7331
Mailing Address - Country:US
Mailing Address - Phone:612-799-1691
Mailing Address - Fax:
Practice Address - Street 1:195 W 14TH
Practice Address - Street 2:
Practice Address - City:RIFLE
Practice Address - State:CO
Practice Address - Zip Code:81650-4700
Practice Address - Country:US
Practice Address - Phone:970-625-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-18
Last Update Date:2014-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO905457124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist