Provider Demographics
NPI:1851516884
Name:J. WADE NICHOLS DMD, PA
Entity Type:Organization
Organization Name:J. WADE NICHOLS DMD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INS. COORD.
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:
Authorized Official - Last Name:DIBENEDETTO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-554-5300
Mailing Address - Street 1:4605 OLEANDER DR
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-5739
Mailing Address - Country:US
Mailing Address - Phone:843-554-5300
Mailing Address - Fax:843-554-1067
Practice Address - Street 1:4605 OLEANDER DR
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-5739
Practice Address - Country:US
Practice Address - Phone:843-554-5300
Practice Address - Fax:843-554-1067
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC19561223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSC19560Medicaid
SCZA9681Medicaid