Provider Demographics
NPI:1881002434
Name:NICHOLSON, KEIRA LYNN (DDS)
Entity Type:Individual
Prefix:
First Name:KEIRA
Middle Name:LYNN
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7225 OHMS LN STE 180
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55439-2172
Mailing Address - Country:US
Mailing Address - Phone:952-345-0290
Mailing Address - Fax:952-920-0105
Practice Address - Street 1:7225 OHMS LN STE 180
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55439-2172
Practice Address - Country:US
Practice Address - Phone:952-345-0290
Practice Address - Fax:952-920-0105
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-28
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND13450122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist