Provider Demographics
NPI:1871681734
Name:PHILIP L NICHOLSON DDS PC
Entity Type:Organization
Organization Name:PHILIP L NICHOLSON DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:NICHOLSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-831-4240
Mailing Address - Street 1:150 N INDIANA ST
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46158-1506
Mailing Address - Country:US
Mailing Address - Phone:317-831-4240
Mailing Address - Fax:317-831-4473
Practice Address - Street 1:150 N INDIANA ST
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46158-1506
Practice Address - Country:US
Practice Address - Phone:317-831-4240
Practice Address - Fax:317-831-4473
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12007371B1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty