Provider Demographics
NPI:1821077900
Name:NICHOLS, JOHN THOMAS (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:THOMAS
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 CHERRYWOOD RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-2101
Mailing Address - Country:US
Mailing Address - Phone:502-897-7422
Mailing Address - Fax:
Practice Address - Street 1:775 WAUKEGAN RD
Practice Address - Street 2:SUITE 200
Practice Address - City:DEERFIELD
Practice Address - State:IL
Practice Address - Zip Code:60015-4342
Practice Address - Country:US
Practice Address - Phone:800-317-0711
Practice Address - Fax:800-434-7113
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-17
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009437A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200512620Medicaid